Dialysis patients hospitalized due to inadvertent use of cleaning solution
By: Sarah Wilson
A State of Missouri investigation found that a cleaning solution, commonly used in dialysis, was inadvertently added into U.S. Renal Care’s water supply, causing eight patients to be hospitalized after receiving dialysis on Dec. 3. U.S. Renal Care is located at, but not affiliated with, The Cedars of Town and Country.
A press statement from U.S. Renal Care called it a “one-time humor error.”
“Several of our patients reported not feeling well during their dialysis treatments,” the press statement said. “We immediately stopped dialyzing patients. As a further caution, we advised patients to go to the hospital and helped make arrangements for them to do so.”
“As soon as we became aware that something was not right, we immediately stopped dialyzing all eight patients and out of an abundance of caution, advised them to go to the hospital for observation,” Tom Weinberg, spokesperson for U.S. Renal Care, said in a statement on Dec. 4. “Most importantly, we have been talking with patients and their families and thankfully all patients are stable.”
He noted that the company was “communicating with the state health department to confirm the water system is absolutely safe before we reopen our facility.”
“In the meantime, we are making sure every patient has a place to dialyze, and our thoughts remain with them,” Weinberg continued. “Our top priority is the health and safety of our patients and we have taken added precautions to ensure this does not happen again.”
A registered nurse who has worked with dialysis patients for more than 30 years and spoke on the condition of anonymity, said during dialysis, water used for treatments is viewed as medicine, “and it has to be purified.”
“The water system has to be disinfected periodically because you don’t want bacterial to get in it,” she said. “Dialysis patients are exposed to an incredible amount of water, so if there is a chemical or contaminant in there, it’s a large quantity that they’re exposed to, so that can be harmful.”
She said the Centers for Disease Control and Prevention, Medicare and Medicaid have strict guidelines to ensure that all dialysis facilities are adhering to a set cleaning schedule and are trained properly.
“The other side of it is telling caregivers how to identify when something’s wrong and what to do in the event that you start seeing something wrong,” she said. “Fortunately, all the patients as far as I know are going to recover and all going to be OK after this, but it does give everybody the reminder of the importance of what they’re doing and taking the time to do it.”