One patient dead after contaminated water used in dialysis machine at Royal Alexandra Hospital in Edmonton

Alberta man dies after cleaning chemical leaked into dialysis machine by Catherine Griwkowsky, Postmedia, June 2., 2015, Calgary Sun

One of four patients being monitored after their dialysis machine water was contaminated by a cleaning chemical at the Royal Alexandra Hospital in Edmonton on Friday has died.

The man died Sundaiy evening, though it’s not known if the patient’s death is connected to the water contamination, Alberta Health Services said in a Tuesday statement.

“Our heartfelt condolences go out to the family of the patient who died,” Vickie Kaminski, AHS president and CEO, said.

“This was an extremely unfortunate incident, and our thoughts are with the families and loved ones of all four patients impacted. We apologize that this incident occurred — it should not have happened — and we will do all we can to support the patients’ families and loved ones through this difficult time.”

One other patient remains in hospital, one has been discharged from acute care to subacute care and one has been discharged.

These patients continue to be monitored by AHS. All four patients were on dialysis for five minutes at the time the contamination happened.

The patients, who were hooked up to the machine containing the chemical, had been closely monitored after it was found a contract worker accidentally turned on a valve during regular system cleaning.

The valve caused the release of the chemical into the dialysis machine water supply. The contamination was discovered during regular monitoring.

“There was no indication from any of the patients that they had experienced any kind of symptoms,” Kaminiski said, adding their anxiety was heightened.

The contaminated water supply was immediately turned off, and while the supply was being cleaned, the hospital put patients on portable dialysis machines.

Dialysis machines filter a patient’s blood, and are primarily used for those with reduced kidney function or failure.

The water used in dialysis treatment needs to be pure, and the lines in the machine itself need to be cleaned regularly.

The cleaning chemicals include hydrogen peroxide and peracetic acid. [What were the other chemicals?] While little is known about internal exposure, it is believed the effect is similar to a sunburn inside the body.

Kaminski said steps have been taken to ensure nothing like this happens again.

AHS is installing extra lock-outs on valves, improved valve indicators, and better signage, to ensure the water supply is protected from inadvertent contamination.

AHS is conducting a quality improvement process that will involve the clinical team and facilities maintenance to identify ways to prevent similar such incidents from occurring in the future, including formal human factors analysis.

The results of this review will be shared with the patients’ families and throughout AHS.

The medical examiner has been notified. The man’s age and where he is from were not released.

“We apologize to all of our patients that this happened,” Kaminski said. “We don’t want it to cause any lack of trust in the health-care system.”

Mortality of dialysis patients varies widely based on several factors including age, stage of renal disease and the purpose of dialysis. [Emphasis added]

One patient dead after contaminated water used in dialysis machine at Royal Alexandra Hospital by Alexandra Zabjek, June 1, 2015, Edmonton Journal

Alberta Health Services has confirmed the death of a patient who received kidney dialysis with contaminated water at the Royal Alexandra Hospital in Edmonton.

“It is not known if the patient’s death is connected to the water contamination issue,” AHS said Tuesday in a news release. The patient died on Sunday, two days after receiving dialysis treatment at the hospital.

AHS has confirmed that on the morning of May 29, a wrong valve was opened during a routine system cleaning, which released a chemical into the water supply used for dialysis at the hospital.

“The dialysis water supply was immediately turned off and the water supply was thoroughly flushed and cleaned, and has been safely in use since the evening of May 29. While the system was being cleaned, portable dialysis systems were used,” AHS said in a news release.

Four dialysis patients received treatment at the hospital that day. One other patient remains in hospital, one has been discharged from acute care to subacute care and one has been discharged.

“Our heartfelt condolences go out to the family of the patient who died,” Vickie Kaminski, AHS president and CEO, said in a written statement.

“This was an extremely unfortunate incident, and our thoughts are with the families and loved ones of all four patients impacted. We apologize that this incident occurred — it should not have happened — and we will do all we can to support the patients’ families and loved ones through this difficult time.”

Kaminski said steps have been taken to ensure an incident like this does not happen again. “AHS is installing extra lockouts on valves, improved valve indicators, and better signage, to ensure the water supply is protected from inadvertent contamination.”

AHS said it cannot comment further on specific patient conditions or cases to protect patient privacy.

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