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Background and Aims Patient safety programs need a well-structured organization to facilitate proactive and fair reporting, prompt evaluation analysis and timely feedback followed by measure implementation and auditing. To analyze all types of incidents in our network from Jan.1st to Sept. 30th, 2019 by two different levels (Corporate and Country) of medical management alert. Method Our institution has tracked all incidents under a structured process program for the last 10 years, according to 4 incident types (Patient related, Staff-visitors, Products and Equipment) and 54 subcodes. Incidents are considered as serious when they may be life-threatening or result in death, impaired body function/structure and/or are deemed serious based on appropriate medical judgment. Communication to Health Authorities applies in accordance with local country regulations. “Serious incidents” are immediately notified to the Corporate Office and to each Country Medical lead, whilst different codes may generate alerts into Corporate or Country. Results A total of 68.399 incidents (2.7 incident/patient/year) were reported during Q1-Q3 2019. Total incidents/1000 treatments were 17.1 (12.1 were patients related incidents). Causes for alerts at corporate level (n=65) were: cardiorespiratory arrest (28%); unexpected death (15%); seroconversion (9%); hemolysis (8%), severe hypotension (6%) and air embolism (3%). Reported incidents at country level (n=655) were almost half ascribed to equipment [water supply, power failure and flooding (41%)], medication errors (36%), venous needle dislodgment (19%) and Injuries (3%). Conclusion Despite continuous efforts to get better results, there is room for improvement on better staff compliance with our standard operating procedures especially regarding medications and venous needle dislodgment risk assessment.

Background and Aims Patient safety is considered of paramount importance under any qualified provision of care, but results from routine tracking of incidents have scarcely been reported, even when that may negatively impact survival. To analyze all types of incidents in a multinational renal service provider network from Jan.1st to Sept. 30th, 2019. Method For the last 10 years, our institution has tracked all incidents under a structured process program, as well as, educated our staff in the importance of proactively reporting and analyzing incidents in a quarterly basis at the clinic, by country and globally. Incidents are categorized in 4 different types: A-Patient related; B-Staff and visitors; C-Products and D-Equipment. Different incident codes are assigned to each type. Results A total of 68.399 incidents (2.7 incidents/patient/year) have been reported during Q1-Q3 2019 (higher than in 2018: 2.2). This means an increase of 20% in the total number of reported incidents. Total incidents/1000 treatments was 17.1 (12.1 patient-related incidents). Reporting follows a heterogeneous pattern among countries, being lowest in Argentina and highest in the UK. Top 5 reported incidents were as follows: Codes A15 (voluntarily shortened treatment) and A14 (Patient did not show up), both related to patient adherence to treatment, accounted for 36% of total incidents, vascular access (VA) complications (A4) for 10.5%, change of dialyzer and/or blood lines due to clotting (A2) for 8.6% and recurrent minor monitor malfunction (D1) for 6.7% of incidents. Codes related with unexpected death or cardiorespiratory arrest are not present among the total global top 10 incidents. Conclusion Detailed tracking of incidents and comparison between countries have potential to increase quality of care. Room for improvement recently made the Corporate Medical Office to launch new strategies on VA management, anticoagulation and patient compliance, among others. This large series may help other institutions to better monitor and standardize patient safety.