What does safety look like in your nephrology practice setting? Do you feel comfortable reporting errors, near-misses, and unsafe conditions? Do you believe your patients perceive they are safe in the dialysis, peritoneal, transplant, or nephrology clinic setting? Do you work with other health care team members to ensure patient safety at all costs?
Safety is the responsibility of every person working in your nephrology practice setting. Reporting errors, near misses, and unsafe conditions and practices is the responsibility of every employee and provider because mistakes are made every day in the health care environment. This was recognized 15 years ago when To Err Is Human: Building a Safer Health System (2000) was published by the Institute of Medicine (IOM). This cutting-edge report emphasized the responsibility of health care providers to examine faulty systems and processes within their organizations with the goal of improving patient clinical outcomes. This report also accentuated the need to develop a culture that encourages all health care providers-regardless of position and profession-to advocate for patient safety and to question practices that place patients at risk for harm. Since the time of the 10M report, significant attention has been given to defining the terms of patient safety culture and climate, developing tools to measure these components, and conducting research to establish the relationship between safety culture/ climate and patient outcomes (DiCuccio,2014).
In an era that places safety at the forefront of health care in nearly all practice settings, a study of patient safety culture in nephrology nurse practice settings had not been conducted. Nephrology nurse practice settings utilize highly technical equipment in a fast-paced environment, and studying safety and safety culture was long overdue. In 2014, we conducted the first national study to examine patient safety in nephrology nurse practice settings (Ulrich & Kear, 2014a).
Nephrology Culture of Safety Study
Patient safety culture has been defined as “the values shared among organization members about what is important, their beliefs about how things operate in the organization, and the interaction of these with work unit and organizational structures and systems, which together produce behavioral norms in the organization that promote safety” (Singer et al., 2009, p. 400). We used survey items from two Agency for Healthcare Research and Quality (AHRQ) patient safety culture survey tools and compared the results to AHRQ published comparative data. The overall response rate of 979 individuals was much higher than expected, indicating nephrology nurses have a strong interest in patient safety culture and practices. Detailed demographic data are shown in Table l.
The overall rating of patient safety in nephrology nurse practice settings was favorable, but with room for improvement (Ulrich & Kear, 2014a). Many nurses reported working in a health care environment with a strong focus on patient safety and described sound safety systems and process; others described less positive environments. Issues that received scores lower than the AHRQ comparative data included patient hand-offs, medication errors, communication lapses, prioritization of care, staffing, and workload. Respondents described a rushed nature in the practice setting, resulting in incomplete work, missed medications, poor infection control compliance, and a lack of communication between team members. It was also consistently noted that nurses in manager /administrator roles rated the patient safety culture higher than did nurses in direct care roles. This finding is consistent with other published research. Respondents employed in not-for-profit organizations rated the patient safety culture higher than did respondents working in for-profit organizations (Ulrich& Kear, 2015). Teamwork and overall staff training received high scores.
In addition to the AHRQ-based questions, Ulrich and Kear posed two open-ended questions asking nephrology nurses to share their experiences about patient safety and patient safety culture. Nurses were asked to describe a patient safety issue in their unit that causes/caused concern and how it was resolved. Nurses were also asked to provide additional information and comments about patient safety, errors, or event reporting in the practice setting. The nurses had much to tell about safety-related challenges and successes.
The analysis of the nurses’ responses resulted in the identification of several areas of concern, including under reporting of events, inadequate and unsafe staffing levels, long work hours, cumbersome documentation systems, infection control failures, compliance issues with policies and procedures, inadequate training, and communication breakdown (Kear & Ulrich, 2015). While many safety culture and safety problems were reported, there were stories of great successes in managing the identified issues. For every theme that identified a safety problem, there were stories of successful strategies (see Figure 1). The themes that supported safety culture best practices included non-punitive and transparent event reporting, fall reduction strategies, improved mediation administration practices, and scheduled safety huddles and safety meetings. One nurse described a well developed safety system in her unit (Kear & Ulrich, 2015, p. 119).
My health care organization has implemented safety behaviors that include daily safety huddles, SEAR, STAR (stop, think, and review), practice with a questioning attitude, and encourage all employees to speak up by saying, ‘1 have a concern,” when there is any doubt about an issue that could potentially harm a patient. Since implementing these safety behaviors, staff has more autonomy and respect for each other when someone speaks up and practices with a questioning attitude. The time span between serious safety events is growing
Interprofessional approach to safety
It was no surprise that teamwork, training, and collaboration received high scores. Teamwork has long been a cornerstone in nephrology practice settings due to the interprofessional collaboration that is necessary to provide holistic care to patients with a complex disease process such as kidney disease. Well before the term “interprofessional collaboration” started appearing in health care text books, research funding grants, and classroom lectures, health care providers in nephrology settings were working as a team through multidisciplinary care planning, care coordination, and discussion of the plan of care at meetings that included a variety of health care providers and often the patient. This approach also placed patients at the center of care. Nephrology practice was an early adopter of patient-centered care due to the choices patients must make regarding renal replacement therapies and transplantation for management of kidney failure. Regardless of the modality selected by the patient to manage the kidney failure, some degree of patient directed self-care is required. The interprofessional team provides support and education for this patient self-care regimen.
Irrespective of the sophistication of the safety policies and practices implemented in a practice setting, outcomes that enhance safe practice have long been monitored within nephrology settings. But, as described by some nurses, the implementation of the policies is sometimes enforced in a dictatorial manner, which results in fear and under-reporting of events. The following is an example of a negative culture of safety:
Our supervisor is very condescending to the staff She is unapproachable so staff speaks to her only when necessary. If a problem is reported, it is held against us.
Other nurses described a safe and open atmosphere for reporting of near-misses and events. Safety hudles, time-outs, and on-the-unit meetings were often mentioned as ways to communicate. A nurse described a positive interprofessional approach to safety adopted by members of the staff (Kear & Ulrich, 2015, p. 119).
We have a safety committee that is composed of managers, nurses, technicians, a social worker, and nutritionist from each of our units. We meet monthly and review any event. All staff members perform two safety trainings a month. All units are Five-Diamond Safety certified by the Network. We have a patient representative committee. We are very safety oriented for staff and patients.
Fostering a culture of safety is a responsibility that belongs to all health care team members. The first step in this process is to establish safe and open lines or communication. All members of the health care team must report near-misses, unsafe conditions, and errors. Administration has the responsibility to investigate and respond to the near-misses and reported errors in a timely manner. A nurse reported in the study that errors presented by staff do not seem to result in corrective action that changes patterns of behavior. Interprofessional collaboration and quality improvement meetings provide a vehicle to open the lines of communication to discuss a culture of safety. Direct care staff should be invited to quality improvement meetings, as well as any other meeting that involves safety issues. Procedures for documenting errors and near-misses require efficiency and ease of use.
The number of responses to this survey and the lengthy narratives indicate that this is an important topic to nephrology nurses. The nurses’ stories described many areas of success and challenges yet to be tackled. Patient safety is known to form the foundation of healthcare delivery, just as biological, physiological, and safety needs form the foundation of Maslow’s Hierarchy of Needs theory (Ulrich & Kear, 2014b). As a member of the interprofessional nephrology team, nephrology nurses are well positioned to take the lead in creating a culture of safety, Together with other team members, nephrology nurses can identify and report patient safety issues and near-misses, examine root cause analyses for the errors and near-misses, develop policies and procedures to address the safety issues, and explore safety concerns reported by patients.
- DiCuccio, M.H. (2014). The relationship between patient safety culture and patient outcomes: A systematic review. Journal of Patient Safety, ePub ahead of print.
- Institute of Medicine (10M). (2000). Kohn, LT., Corrigan, J.M., & Donaldson, M.S. (Eds.).To err is human: Building a safer health system. Washington, DC: National Academy Press. Retrieved from http://www.iom.edu/ Reports/1999/To- Err- is-Hurnan- Building- A-Safer? Health-System.aspx
- Kear, T., & Ulrich, B. (2015). Patient safety and patient safety culture in nephrology nurse practice settings: Issues, solutions, and best practices. Nephrology Nursing Journal, 42(2), 113-122.
- Singer,S., lin, S., Falwell, A., Gaba, D.,& Baker, l. (2009).
Relationship of safety climate and safety performance in hospitals. Health Services Research, 44(2), 399-421. DOl: 10.1111/j.1475-6773.2008.00918.x
- Ulrich, B., & Kear, T. (2014a). Patient safety culture in nephrology nurse practice settings: Initial findings. Nephrology Nursing Journal, 41(5), 459-475.
- Ulrich, B., & Kear, T. (2014b). Patient safety and patient safety culture: Foundations of excellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456,505.
- Ulrich, B., & Kear, T. (2015). Patient safety culture in nephrology nurse practice settings: Results by primary work unit, organizational work setting, and primary role. Nephrology Nursing Journal, 42(3), 221-236.
Dr. Kear is an assistant professor of nursing at Villanova University and a nephrology nurse at Liberty Dialysis. She is a member of the Nephrology Nursing Journal Editorial Board, the American Nephrology Nurses’ Association’s Education Committee, and the ANNA Keystone chapter. Dr. Ulrich is editor of the Nephrology Nursing Journal and professor at the University of Texas Health Science Center at the Houston School of Nursing. She is a past president of ANNA and a member of the Sand Dollar chapter.