Optimizing patient safety during hemodialysis.

摘要

The greatest opportunities and challenges, however, probably involve identifying "unknown unknowns" that affect patient safety. Two salient studies,8-9 separated by more than 40 years and each published in JAMA, illustrate the inherent value of alert clinicians and researchers working together to illuminate "unknown unknowns" in dialysis care.In 1968, during the early days of dialysis therapy, clinicians made the serendipitous observation that transient neutropenia occurred 2 to 15 minutes after starting dialysis. The neutropenia was followed by the appearance of circulating immature neutrophils and by the end of dialysis the white blood cell count was normal.