Edmonton dialysis patient treated with contaminated water dies

EDMONTON — Alberta Health Services says one of four dialysis patients mistakenly treated with contaminated water in an Edmonton hospital last week has died.

It’s not yet known if the patient’s death on Sunday was connected to the water problem two days earlier at Royal Alexandra Hospital.

Another patient remains in hospital, one has been moved off the acute-care unit and another has been discharged.

Health services president Vickie Kaminski told reporters Tuesday that the contamination was due to “human error.”

A wrong valve was opened during regular system cleaning and a chemical was released into the water used for dialysis.

“Instead of having it come out into the discharge bin, it went back into the line that was circulating through the dialysis equipment,” she said.

She said the chemical was a combination of peracetic acid and hydrogen peroxide, which would cause “a sunburn-like reaction inside the body.”

The mistake was discovered within a few minutes, she said, and the dialysis water supply was immediately turned off. The four patients were notified and portable dialysis was used while the water was flushed and cleaned.

Exposure was limited and the four patients did not feel any immediate effects, Kaminski said.

She didn’t know what pre-existing health problems the patients were suffering from that required the dialysis.

The agency is conducting a review to ensure the mistake doesn’t happen again.

Workers are installing extra lockouts on valves, improving valve indicators and posting better signage to ensure the water supply is protected from contamination.

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

“We want people to be reassured that no one is at risk, that we have in fact resolved this issue and that there is no residual problem for our dialysis patients.”

The Canadian Press

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