Trends and Causes of Incident Reports in an Ambulatory Hemodialysis (HD) Center

Background: Increasing rates of ESRD due to obesity, DM, and hypertension, leads to more in-center HD—83.8% of new ESRD cases in 2023 (USRDS). Urban dialysis units treat up to 100 patients daily under tight staffing. Given that each dialysis machine circulates 500 ml of blood/min, safety is critical. Our goal was to examine incident trends, define causes, and identify areas to prevent escalating events in an outpatient dialysis setting. Methods: We analyzed dialysis-related incidents reported in SUNY Downstate’s Safe Qual system from 12/1/2022 - 12/31/2023, including incident type, date, time, cause, and patient impact, with correlation to weekday, staffing, and resources. 29 incidents were reported (1.32 per 100,000 patient-years). Two incidents involved patient harm—one serious, one minor. Most incidents (29%) involved treatment delays from malfunctioning machines, and 43% were on Mondays. Results: Most Monday incidents were related to equipment malfunctions causing delayed treatment starts, due to a backlog of unresolved equipment issues from weekends. Incident frequency were lower on days with less patients, with no correlation to staffing. Equipment examined after malfunction showed sediment buildup, raising concern about water quality. Conclusion: We now perform immediate equipment repairs using in-house certified technicians. We’re working to install water filters to reduce sediment reaching the RO system. Staff training on timely incident reporting is ongoing. While limited by small sample size and single-center scope, the data point to equipment issues as a leading, preventable source of delays that impact patient care and satisfaction.