ORLANDO – On April 20, Beth Ulrich EdD, RN, FACHE, FAAN, and Tamara Kear, PhD, RN, CNS, CNN gave a presentation at the American Nephrology Nurses’ Association 46th annual symposium on the results of a survey they conducted on nephrology nurses to assess patient safety culture in the dialysis setting. The study data was published in the March/April issue of the Nephrology Nursing Journal

Before presenting the data, Ulrich, who is editor of the NNJ and professor at the University of Texas Health Science Center at Houston School of Nursing, asked the audience if they would like to be a patient in a hospital or dialysis clinic, and the audience responded with "no."

"Well we need to do something about that,” she said.

Ulrich gave an introduction to patient safety culture, and how important it is to a dialysis clinic and health care in general. More than 400,000 deaths a year in the United States are due to errors in health care facilities, she said. Transparency, integrated care, consumer engagement, joy and meaning in work, and medical education reform are the most important factors to improve patient safety culture in health care settings. Non-punitive transparency, she said, is key; even checklists, which have a history of increasing safety, are not helpful without transparency, Ulrich said.

About the survey
The survey data included the responses of 929 nephrology nurses, the majority of which were RN direct care providers (52.4%). Respondents also included managers and administrators (26.8%), educators (9%) advanced practice nurses (5.4%) and those who checked other (5%). One percent of respondents did not check a specialty. The survey, accessed online, was composed of items from two Agency for Healthcare Research and Quality (AHRQ) patient safety survey tools.

Problem areas identified

Under-reporting of events and near misses
The most commonly discussed theme in the survey was the under-reporting of events and near misses. This was attributed to the lack of time and the large amount of paperwork required to report events. Without reporting, Kear said, staff never get the chance to learn from mistakes, and are doomed to repeat them. Kear, an assistant professor of nursing in Villanova, Pa., and a nephrology nurse at Liberty Dialysis, said many respondents expressed frustration that their clinics are often in crisis mode, and tend to implement temporary solutions that are forgotten over time. 

Inadequate and unsafe staffing
Respondents reported inadequate staff-to-patient ratios that often don't take into account the setup of a clinic or acute dialysis center. Acute dialysis nurses mentioned they are often in remote parts of the building and have no support when something goes wrong.

Long work hours
A decrease in staff has led to long work hours for many nurses. Long shifts, up to 30 hours for some, leads to fatigue, and the increased possibility of mistakes, nurses reported.

Nurses reported communication problems when patients are transitioned from one facility to another, or between levels of care. Hospital staff often don't tell clinic doctors and nurses of the medication patients are taking. Lack of communication between inpatient and outpatient units was a common concern, and some nurses expressed frustration that many facilities are not open every day, and communicating is limited to only certain days of the week. Other nurses reported that staff might leave a shift without notifying anyone of any updates to a patient's care.

Lack of infection control compliance
The main reasons cited for failure to comply with infection control procedures was a lack of training and a generally rushed atmosphere. Kear described the rush of getting patients on an off hemodialysis machines as an "assembly line mentality."

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Best practices

Event reporting
Nurses who felt the best about their practices described feeling comfortable because they worked in a non-judgmental, blame-free environment where event reporting was encouraged.

Ulrich stressed that it is important to the patient safety culture for event reporting to be non-punitive. It is critical, she said to always be transparent and report errors and near misses 100% of the time, without exception.

Many respondents described working well with other members of the team. The happiest respondents worked in settings that encouraged teamwork.

Safety meetings
The greatest achievements respondents described were the success of safety meetings and quality and compliance monitoring. Many nurses described the usefulness of sophisticated reporting systems.

Making improvements to dialysis patient safety
Ulrich offered the following steps to improve the culture in a dialysis setting:

Assess: look at safety issues in your unit. Listen to others' opinions about safety in the dialysis clinic.

Discuss: Data starts conversations, Ulrich said. And the data doesn't have to be from a study. It can be from careful observation in a dialysis unit.  

Be transparent: Report errors and near misses 100% of the time, without exception

Learn: Learn from mistakes, and look and what other dialysis units are doing correctly.

Make a plan: Make a plan to fix things that need to be fixed. Start simple with one thing at a time.

Pick one thing you can do in the next 30 days to improve patient safety in your dialysis unit, Ulrich told attendees.

"No other work moves forward if, above all else, a patient is not safe in our care," Ulrich said.