Wrong Blood Bath on Dialysis

Saturday   2014/01/25

On Saturday the wrong blood bath was used for me, instead of Calcium at 1.3mmol/L, 1mmol/L was used.  When asked about it, the answer given was that the correct one run out. However on the work sheet this incident was not even mentioned, 1.3 was recorded as usual, what get recorded on the sheet is very selective, something could simply left without a trace.

This is not the first time that wrong dialysis solution was used without the patient’s knowledge or letting aware of it’s happening. One day the incorrect potassium solution was used for a patient, after 3 hours on a 5 hour session the blood bath was changed from K2 to K1. I noticed the whole episode including the patient’s extreme uncomfortable behaviour, but I don’t think he knew what was happening to him himself. Not so many patients use K1. After the incident, he was treated extra nice.

Once  I was bathed with a wrong solution when my potassium at 2.9, and I felt terrible, and felt better only after the doctor let me swallow 2 chlorvescent dissolved in water which taste horrible. Nobody should take medicine to boost potassium level after dialysis, something happened when it should never have.

I suspect the same thing happened to me more than once, however, not just for one day but lasted until now. K3 bath seems more suited for my condition which was exactly what I was prescribed in the beginning. Since I go everywhere to dialyse, along the line perhaps one centre changed it to K2 which is a much popular bath which is also acceptable even thought not optimal for me at the time, the rest simply just followed what had been done, now I am stuck with it.

Right or wrong, something is easier changed than others, not the other way round.

I find that when something happened by mistake or not, is very easy, change it back correct or not, is very hard. The same also goes with other things. If they are convinced that fluid should be taken, not to take proof to be difficult. If the alarm of the machine sounds continuously, without identifying the real cause, pump rate could be easily reduced. But when one doesn’t feel too great and ask to reduce the rate, they would say low rate leads to bad clearance hence not to reduce without much fuss. If you are on K2, they don’t change to K3 easily. If you need a higher temperature, it is almost impossible to ask. As for the use of heparin, even it proofs that it causes thrombocytopenia they still won’t change to something else or reduce the dose easily. I heard one patient suffers severe itchiness because of it he was changed to use another drug. For me I still use heparin even it make my platelet count low, since it is invisible, it is hard to change.