POS-550 INCIDENCE OF HYPOGLYCEMIA IN HEMODIALYSIS PATIENTS CAUSED BY FAILURE OF COMMUNICATION BETWEEN TWO HEMODIALYSIS CENTERS- A CASE

Abstract

Patient Safety is considered a serious public health problem. Very often patients suffer damage that could have been prevented or mitigated during their care. Family members and health professionals are also victims of this complex process. Communication is one of the 6 international safety goals in patient care and considered a very important one. The lack of integrated and effective communication processes between the various teams of professionals and health services are factors that contribute to the failure in care. Our objective was to report the experience regarding the incidence of hypoglycemia in hemodialysis patients due to communication failure. A descriptive method of analysis the experience of hypoglycemia events recorded in a hemodialysis service of a private clinical-surgical hospital, located in southern Brazil, occurred in October 2020. The Nephrology and Dialysis Center started its activities on September 21, 2020, replacing another 35 years of experience terciary clinic. For almost two years, the processes and protocols paying attention to patient safety were mapped. The acquisition of hemodialysis inputs needed to be similar to the older clinic, because the target audience was composed of the same clients (n = 93), with a mean age of 72.4 years, 45 (50.5%) patients with diabetes mellitus. The information requested was: dialysator priming and the composition of hydroelectrolytic concentrates. The verbally reported information regarding the hydroelectrolytic concentrate, was that there were a higher consumption of glucose-free solution. This information served as the basis to purchase the supplies for the patients. During the first month of operation, an important incidence of hypoglycemia was observed in hemodialysis patients. During the reported period, 1,104 hemodialysis sessions were performed and 217 (19.7%) hypoglycaemia (HGT <80mg/dL). The episodes were managed with administration of intravenous hypertonic glucose, according to the institutional protocol. No patient presented worsening of the condition or needed hospitalization. The identification of the root cause allowed the elaboration of an action plan and acquisition of a greater amount of hydroelectrolytic concentrate with glucose. With the use of glucose solution, partial data showed the occurrence of 49 episodes of hypoglycemia in the first half of the following month, a reduction of 65% compared to October. Failures in institutional communication processes is also pointed out as a source of risk of adverse events. Another critical communication process for the risk of adverse events is between the pharmacy, nursing and medical staff. Situations of failures of writing and interpretation of medical prescription, as well as the dispensing and preparation of medications are moments. prior to administration of medications that can induce the error of the nursing team. The case reported illustrates the impact on the entire drug chain due to misinformation about the hydroelectrolytic solution, which led to the failure of the administration, pharmacy, doctors and nurses that are part of the new service. Events could have been avoided, as diabetic patients with chronic renal disease may present with episodes of hypoglycemia, usually asymptomatic, during hemodialysis sessions when using glucose-free dialysate.