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Dislodged Dialysis Line May Cause Brain Injuries

Approximately 400,000 Americans suffering from kidney failure today rely on renal dialysis as a lifesaving medical procedure. But despite its benefits, dialysis in some cases can be deadly.

Dialysis is an intricate system. A patient’s blood passes through lines to a dialysis machine where it is filtered. The blood then returns back through the lines into the patient’s body. If one of these lines is separated from the system, it causes serious life-threatening problems to the patient.

Dialysis Medical Malpractice

In 2001, Kathryn Stevens was receiving dialysis in Cleveland, Ohio. One of her lines to the dialysis machine became disconnected. Blood was passing out of her body and into the dialysis machine, but new oxygen-rich blood was unable to filter back into her body. The medical staff failed to notice the problem until Kathryn fell unconscious from her chair. Since she was not receiving clean, oxygen-filled blood, Kathryn’s brain was deprived of the vital oxygen it needed to function, causing irreparable brain damage. Before she passed away, Kathryn lived in a vegetative state for five months where she could not speak or eat on her own.

Dialysis Line Dislodgement

Several dialysis medical errors can occur that result in patient brain injury and death. When one or more lines are separated (called line dislodgement) from the patient or from the dialysis machine, the patient blood concentration levels become unbalanced.

If left unattended, lost blood pools around the patient or spills onto the floor and creates a harrowing condition for the patient. It only takes ten minutes for a patient to suffer a brain injury as a result of line dislodgement.

Inadequate Staffing for Dialysis

Other medical errors are not due to equipment failure. Unfortunately, staffing problems and user error create environments for line dislodgement. Dialysis center inspectors find that most fatal or serious incidents occur when a facility is understaffed, or when staff members are working 12 to 16 hour days.

Nurses with an overwhelming patient load in many cases fail to see dislodgement or another problem. Since dialysis machine false alarms are frequent, staff may reset or turn down the volume of alarms without checking to see if there is indeed a connection problem. Further, regulations require that lines be visible at all times, but patients often cover them up with a blanket for comfort or privacy.

Technology and Dialysis

Efficient technology, ironically, is also a contributing factor to loss of blood. Dialysis machines today pump blood at a faster rate than they did a couple of decades ago, which means that should a line become dislodged, blood pumps out quicker and less time is needed for a serious accident to occur.

Dialysis is a life-saving procedure for thousands of individuals. However, unfortunately, dialysis medical errors and accidents such as dislodgement do happen and often have serious, even fatal, consequences.

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