“The dialysis unit is a poster child for safety issues,” Alan Kliger, MD, clinical professor of medicine at Yale University Health Systems, said during a session on patient safety in the dialysis unit at the National Kidney Foundation’s 2016 Spring Clinical Meetings.
Dialysis is a complex, highly technical treatment, said co-chair of the session, Renee Garrick MD, professor of clinical medicine, vice dean, and section chief of renal for Westchester Medical Center, New York Medical College. The treatment involves multiple policies and processes, complex equipment, and a changing patient physiology. Garrick said that more than two million outpatient dialysis treatments are performed annually in the U.S., and considering all the potential for human error, it is generally very safe. “But we can do better,” she said.
She asked the audience to grade the overall safety in their dialysis clinic:
- Excellent: 9%
- Very good 42%
- Acceptable 43%
- Poor 6%
- Failing 0%
Then she showed data from a 2007 RPA Health and Safety Survey Project. The survey included responses from 1,143 patients receiving hemodialysis who had been on hemodialysis for at least three months. When asked how often they worry someone might make a medical mistake, 48.6 % of patients said “sometimes to always.”
Creating a culture of safety
Kliger listed the elements of a culture of safety:
- Acknowledge the high-risk nature of the activity
- Establish safety as a goal
- Evaluate errors and as system failures, not as indiviual’s failures
- Commit needed resources, including time and technology
- Recognize that a “safe” environment is not error free
- Report “near misses” and events in blame- and retaliation-free environment
- Develop processes for peer review and analysis of root cause
In order to reach this culture of safety, all staff must be trained to be 200% accountable. Kliger defined this as an individual not only being accountable for his/her actions, but for all actions he/she encounters in the dialysis clinic. Everyone in the unit must commit to identifying how errors occur and events happen, learning how to prevent errors, and learning and committing to practicing safety habits to prevent errors.
The retaliation free environment is critical, the speakers said. “If mistakes are not reported, we cannot learn from them.” And patients must feel safe enough to speak up when they see an error. The most common cause of mistakes, they said, is a failure to follow procedure, which is often a result of overly complex procedures. The number two cause is understaffing. There is often a disconnect between administrators and front-line staff, Garrick said. Managers are more likely than front line staff to rate their unit as safe. Communication and transparency are necessary to overcome this disconnect.
The safest units have the highest level of teamwork, are committed to reporting errors and near misses 100% of the time, have engaged patients, and encourage a blame-free environment.
- Do you think your dialysis clinic has adequate procedures for reporting errors and near misses?
- Do you think your patients feel safe enough to report error they witness?
- What best practices have worked in your unit?
Let us know your answers in the comment section.