Estimating reporting culture and its link to safety performance by applying hemodialysis error taxonomy

This paper reports a hemodialysis error taxonomy system for not only providing a framework to analyze characteristics of hemodialysis incidents, but also estimating safety status in a dialysis organization. The error taxonomy system was developed by adapting a common health care error taxonomy system to hemodialysis situations. Based on the results of its application to 1,909 incident reports collecting from two dialysis facilities, we obtained a plausible link between reporting culture - which was estimated by average descriptive depth - and safety performance, for which we introduced two indices, i.e., rate of near miss reporting and rate of adverse event reporting. Thus, the error taxonomy system for hemodialysis events proposed in this paper well demonstrated its ability for predicting safety status in a specific dialysis organization.