**3. Strategies for patient safety in hemodialysis**

Patient safety deals with the risks involved in health care and seeks to minimize these risks and reduce or eliminate Adverse Events, which are incidents that result in harm to the patient [1].

Preventing adverse events can improve the quality of care and patient outcomes [11].

Quality comprises the relentless search for identifying flaws in procedures and practices that organize actions, leading to improved processes and results, aiming at the conformities established by regulatory agencies and user satisfaction [12].

Reducing errors and improving patient safety have become a national priority. Patients with chronic kidney disease (CKD) may be at higher risk for adverse consequences of medical care, but few studies have evaluated this issue [10].

The occurrence of AEs can be minimized by changing managerial and professional attitudes, strengthening leadership, improving access to information, quality, maintenance and use of equipment and environments as well as knowledge and encouraging continuing education [7].

Safety culture has received increasing attention in the field of healthcare organizations. Healthcare is becoming increasingly complex, raising the potential for incidents, errors, or failures to occur. Injuries or harm resulting from the care provided are a serious problem related to the performance of health services; unsafe health care causes significant morbidity and mortality worldwide [6].

From this perspective, health institutions must develop strategies for a patient safety culture. The development of protocols that standardize procedures makes the work process safer and more efficient [22].

Professionals should have knowledge about adverse events and their impact on health care, since the incidence of these events is an important indicator of quality [22].

Currently, there is a greater awareness, nationwide, that professionals need to be trained about the measures to be taken in case of failures, in addition to being encouraged to take an honest attitude towards the error, without fear of punishment and effectively involved in the search for safe patient care [36].

Nursing professionals are responsible for most of the care actions and, therefore, are in a privileged position to reduce the possibility of incidents affecting the patient, as well as to detect complications early and perform the necessary procedures to minimize damage [22].

The maintenance of good adequacy of hemodialysis in patients with chronic kidney disease depends directly on an efficient Vascular Access (VA), whose complications have great representativeness among the morbidities in this group. And, considering the importance of the VA, it is worth noting that the effectiveness of therapy is closely associated with its implantation, handling and proper monitoring, affecting the quality of dialysis and, consequently, the well-being and survival of the patient [12].

Adverse events related to vascular access can be avoided using improvements in the care processes used by Nursing, as well as constant evaluation of the results of the practices adopted.

Studies show that catheter-related infections can be reduced when prevention measures are properly applied, such as the use of aseptic technique before insertion, in each manipulation of the device and dressings, antisepsis at the catheter exit site with 2% alcoholic chlorhexidine, adequate staff paramentation (sterile gloves, masks, goggles and aprons), care in catheter maintenance, monitoring of infection signs, continuing education of staff professionals and self-care guidance for the patient [37, 38].

Considering that vascular accesses are an important care practice and are closely related to the quality of care and quality of life of CKD patients, it is believed that the use of checklists can be an important ally in the evaluation of vascular access, ensuring the quality of this therapeutic modality [22, 39].

The Nursing team that works in hemodialysis units must have knowledge about adverse events to be able to identify the risks and the situations that favor their occurrence, to seek alternatives to minimize failures, adopt risk analysis methods and thus ensure the quality of the services [22].

Many hospitalizations may be preventable with better care planning, adequate patient education, and early detection of complications [40].

Strategies to improve patient safety in dialysis units have emphasized the importance of effective communication, reduction of medication errors, correct dialysis, equipment preparation, and infection control [16].

Encouraging the practice of hand hygiene constitutes one of the nine solutions for patient safety, launched in 2007, in the Nine Patient Safety Solutions program, considered the primary preventive measure to avoid harm to patients [12].

The Nine Patient Safety Solutions program is based on patient safety strategies and best practices that have been identified by the WHO World Alliance for Patient Safety. They were developed with feedback from more than 50 patient safety experts from over 100 countries. The strategies come in nine titles and are being made available to WHO member states. The intention is that the strategies will be used to reexamine patient care processes to improve safety [1].

The nine points covered by the program are: Identical medication names; Patient identification; Communication; Correct procedure in the correct place; Control of concentrated electrolyte solutions; Medication accuracy; Care with connections; Single-use of injection and hand hygiene devices [1].

The theme described above is recurrent in health services and treated as a priority by programs and initiatives that focus on safety in patient care, such as the World Alliance for Patient Safety, an initiative of the WHO, which has dedicated efforts in the development of guidelines and strategies for implementation of measures, including adherence to the practice of hand hygiene and, more recently, in Brazil, by the Ordinance of the Ministry of Health No. 529/2013, which establishes the National Program for Patient Safety [41].

Organizations must safely structure the system, helping professionals not to make mistakes. All causes should be analyzed by the risk management service for the development of corrective actions, aiming at the prevention and reduction of adverse events [22].

Among the suggestions to prevent the occurrence of adverse events, continuing education was mentioned as the main measure and as an important action for human resource training and development. The nursing staff of a hemodialysis unit

### *Patient Safety in Hemodialysis DOI: http://dx.doi.org/10.5772/intechopen.101706*

should develop skills to detect and prevent adverse events, adopting strategies to improve the care processes developed in daily practice [22].

Health education can also contribute to patient safety. A good level of understanding of the disease and treatment aspects also positively influences the patient's adaptation and adherence to treatment [42].

This factor could reflect a lower occurrence of adverse events related to hemodialysis treatment.

Dialysis centers must function as high-reliability organizations to improve patient safety. These services must establish a culture of safety, which is based on communication based on mutual trust, common perceptions about the importance of safety and confidence in the effectiveness of preventive measures [21].

In the occurrence of an incident, what is important is the assimilation that the cause of errors and adverse events is multifactorial and that healthcare professionals are susceptible to committing them when technical and organizational processes are complex and poorly planned [22].

The high frequency of different events observed reveals the specialized care needs for the CKD population. Providing safe care for this population, therefore, provides some unique challenges.

Research must advance in understanding the cause of harm, identifying solutions, impact, and transposing evidence to the organization of care. They reinforce that measuring harm is fundamental to know the patient safety problem [43].
