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AHS Provides Update on Dialysis Incident

June 2, 2015

Confirms one patient impacted has died

Audio: AHS Provides
Update on Dialysis Incident

EDMONTON – Alberta Health Services (AHS) confirms that one of the four dialysis patients affected by the accidental contamination of a water supply at the Royal Alexandra Hospital on May 29, died on May 31. It is not known if the patient’s death is connected to the water contamination issue.

One other patient remains in hospital, one has been discharged from acute care to subacute care and one has been discharged. These patients are being monitored by AHS.

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

The contamination was caused during a regular system cleaning on the morning of May 29 when a wrong valve was opened which released a chemical into the water supply used for dialysis at the RAH. It was discovered during regular monitoring. 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.

Kaminski said steps have been taken to ensure an incident like this does not happen 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 to share the learnings.

To protect patient privacy and confidentiality, AHS cannot comment further on specific patient conditions or cases.