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Haemodialysis patients: risks associated with water supply (hydrogen peroxide)

Risks to haemodialysis patients from water supply
Reference number
1071
Central Alert System (CAS) reference
NPSA/2008/RRR007
Issue date30 September 2008
Action date (if applicable) (date field)31 October 2008
DH Gateway reference
10618
TypeAlert

This Rapid Response Report alerts clinical staff to signs of harm in haemodialysis patients and identifies actions for improved information-sharing between clinical and estates/facilities staff.


Water quality for patients receiving haemodialysis is particularly important because they are exposed to high volumes of fluid. In addition the thin dialysis membrane offers weaker protection than the gastrointestinal tract and a compromised renal function reduces the ability to filter out toxins.


In September 2008, the Reporting and Learning System (RLS) received reports from one trust of a cluster of haemodialysis patients being re-admitted with acute haemolysis. One patient died and four others needed blood transfusion.


Investigation revealed that the day before these patients were treated, silver stabilised hydrogen peroxide had been added to the hospital water system to address water quality issues including legionella. The renal unit had not been informed.


Local organisations should ensure that:


  • All clinical staff caring for patients receiving haemodialysis are alerted to clinical signs and symptoms.
  • Working groups and decisions on future changes to water supply include appropriate clinical input, with active engagement of renal technicians.
  • The Medical Director is aware of water supply feeds to dialysis patients, any chemicals added to the water supply, timetable for disinfection and action to implement DH Estates & Facilities Alert 2008-08 (which instructs organisations on steps to ensure safe water supply for haemodialysis).
  • Clinical staff continue to report incidents through local systems and the RLS.
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Risks to haemodialysis patients from water supply - Rapid Response Report
Risks to haemodialysis patients from water supply - Rapid Response Report - 46 KB 1071 - Risks to haemodialysis patients from water supply - Rapid Response Report - 2008-09-30 - V1