copyright 2014 american nephrology nursesÕ association ...review on patient safety and patient...

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 459

Patient Safety Culture in NephrologyNurse Practice Settings: InitialFindings

Patient safety and patient safetyculture form the foundation ofexcellent health care delivery,but achieving patient safety and

creating positive patient safety culturesrequires ongoing, focused efforts ofevery member of the healthcare team(Ulrich & Kear, 2014). The concept ofpatient safety is very basic. It meanskeeping patients safe from harm whenthey are being cared for by a health-care organization – avoiding and pre-venting patient injuries or adverseevents resulting from the processes ofhealth care delivery. Patient safety cul-ture is the organizational culture thatcreates a positive environment inwhich patient safety is most likely tooccur. It has been associated with theoccurrence of fewer ad verse events(Mardon, Khanna, Sorra, Dyer, &Famolaro, 2010; Singer, Lin, Falwell,Gaba, & Baker, 2009), de creasedpatient mortality in intensive care units(Huang et al., 2010), better reporting ofadverse incidents (Braithwaite,Westbrook, Travaglia, & Hughes,2010), and positive assessments of careby patients (Sorra, Khanna, Dyer,Mardon, & Famolaro, 2012). Patient

Beth UlrichTamara Kear

Continuing NursingEducation

This offering for 1.4 contact hours is provided by the American Nephrology Nurses’Association (ANNA).

American Nephrology Nurses’ Association is accredited as a provider of continuing nursingeducation by the American Nurses Credentialing Center Commission on Accreditation.

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This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-ing nursing education requirements for certification and recertification.

Copyright 2014 American Nephrology Nurses’ Association

Ulrich, B., & Kear, T. (2014). Patient safety culture in nephrology nurse practice settings:Initial findings. Nephrology Nursing Journal, 41(5), 459-475. Retrieved fromhttp://www.prolibraries.com/anna/?select=session&sessionID=3102

Patient safety culture has been studied in many practice settings, but there is a dearth ofinformation on the culture of safety in nephrology nurse practice settings. This researchstudy employed the use of an online survey to assess patient safety cultures in nephrologynurse practice settings. The survey was created using items from two Agency for HealthcareResearch and Quality (AHRQ) survey assessment tools – the Hospital Survey on PatientSafety Culture and the Medical Office Survey on Patient Safety Culture. Select items fromthese tools were combined to address the safety of care delivered in hospital and outpatientnephrology nurse practice settings. Almost 1,000 nephrology nurses responded to the survey.Analysis of results and comparison with AHRQ comparative data found high ratings forteamwork, but indicted a continued need for additional education and attention related tohand hygiene, medication administration safety, communication, and prioritization innephrology practice settings. Nurses in all nephrology nurse practice settings need to rou-tinely assess and positively contribute to the culture of patient safety in their practice set-tings, and lead and engage in efforts to ensure that patients are safe.

Key Words: Patient safety, patient safety culture, nephrology, nursing.

GoalTo describe the results of the first national study of patient safety culture in nephrologynurse practice settings.

Objectives1. Describe the first national study of patient safety culture in nephrology nurse practices set-

tings.2. Compare patient safety culture data from nephrology nurses with published AHRQ data.3. Discuss the results of the study in the context of nephrology nursing practice.

safety culture has been defined as “thevalues shared among organizationmembers about what is important,their beliefs about how things operatein the organization, and the interactionof these within work unit and organiza-tional structures and systems, which

together produce be havioral norms inthe organization that promote safety”(Singer et al., 2009, p. 400).

The first major report of patientsafety and patient harm in the modernera was released by the Institute ofMedicine (IOM) in 1999. The IOM’s

Beth Ulrich, EdD, RN, FACHE, FAAN, isEditor, the Nephrology Nursing Journal, and aProfessor, the University of Texas Health ScienceCenter at Houston School of Nursing. She is a PastPresident of ANNA and a member of ANNA’sSand Dollar Chapter. She may be contacted direct-ly via email at [email protected]

Tamara Kear, PhD, RN, CNS, CNN, is anAssistant Professor of Nursing, VillanovaUniversity, Villanova, PA, and a NephrologyNurse, Liberty Dialysis. She is on the EditorialBoard for the Nephrology Nursing Journal,serves as the ANNA Research Committee chairper-son, and is a member of ANNA’s Keystone Chapter.

Statements of Disclosure: Please refer to page476.

Note: Additional statements of disclosure andinstructions for CNE evaluation can be found onpage 476.

Copyright 2014 American Nephrology Nurses’ Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form without the written permission of the American Nephrology Nurses' Association.

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5460

Patient Safety Culture in Nephrology Nurse Practice Settings: Initial Findings

report, To Err is Human: Build ing a SaferHealth System, placed the topic of safetyat the forefront of healthcare practice,research, and education (IOM, 2000).The report estimated that in theUnited States, each year, up to onemillion people were harmed, and98,000 died as the result of preventa-ble adverse events (medical errors).Beyond the cost of human lives, thereport estimated the cost of medicalerrors is between $17 billion and $29billion per year in hospitals. The IOMreport generated a media storm asindividuals realized patient safety inhealthcare organizations was not agiven. Safety initiatives, funding,media attention, education programs,and guidelines were developed andcontinue to be generated as a result ofthis initial study and others that havefollowed. In 2013, James updated theannual estimates of outcomes of pre-ventable adverse events to 400,000deaths and 4 to 8 million occurrencesof serious harm (James, 2013).

Patient safety culture has beenstudied in many practice settings, butthere is a dearth of information on theculture of safety in nephrology nursepractice settings. To the best of theresearchers’ knowledge, this study isthe first national study investigatingpatient safety culture in nephrologynurse practice settings. This article dis-cusses the initial study findings. Futurepublications will explore in-depthqualitative findings and comparisonsof responses from various groups sur-veyed, such as managers and directcare nurses, and for-profit and not-for-profit organizations.

In preparation for the study, theresearchers conducted a literaturereview on patient safety and patientsafety culture. The results of thatreview can be found in the article,“Patient Safety and Patient SafetyCulture: Foundations of ExcellentHealth Care Delivery” by Ulrich andKear in the September/October 2014issue of the Nephrology Nursing Journal(pp. 447-456, 505).

Methodology This research study employed the

use of an online survey to assesspatient safety cultures in nephrologynurse practice settings. Inclusion crite-ria for this study were registered nursesworking in nephrology patient care.Completion of the survey im plied con-sent. All responses were confidentialwith no name identifiers for therespondents or their employing organ-izations. The researchers re ceivedInternal Review Board ap proval priorto conducting the study.

InstrumentThe survey was created using

items from two Agency for Health careResearch and Quality (AHRQ)patient safety survey assessment tools.Select items from the Hospital Surveyon Patient Safety Culture (HSPSC)and the Medical Office Survey onPatient Safety Culture (MOSPSC)were combined to address care deliv-ered in the hospital and outpatientnephrology practice settings. Thesetwo surveys have been used exten-sively. The dimensions of the surveysare shown in Table 1 (AHRQ, 2014a,b). Dimension reliabilities have beenshown to range from 0.63 to 0.90. Inaddition, the survey contained severaldemographic items on the participantsand their employing organizations.Participants in the study were alsoasked to respond to two open-endedquestions. The questions al lowed theparticipants to share information andcomments about patient safety, errors,solutions, and event reporting issuesin nephrology nurse practice settingsor related to nephrology nursing ingeneral. All participants were asked acore set of questions that were applica-ble to all nephrology nurse practicesettings. Additional questions wereasked specific to the respondents’ pri-mary work setting – hospital, outpa-tient hemo dialysis (OP HD) unit, andperitoneal dialysis (PD) unit. Thegroups are referred to as NephrologyNurse Practice Setting – All (NNPS-All) for responses from all respon-dents, Nephrology Nurse PracticeSetting – Hospital for respondentswhose primary work setting was ahospital, Nephrology Nurse PracticeSetting – OP HD (NNPS-OPHD) for

respondents whose primary work unitwas an OP HD unit, and NephrologyNurse Practice Setting – PD (NNPS-PD) for respondents working in peri-toneal dialysis units. The AHRQComparative Databases were used asa comparison for the AHRQ items(AHRQ, 2014a, c). The AHRQHSPSC data are referred to as theAHRQ – Hospital group and theAHRQ MOSPSC data are referred toas the AHRQ-Outpatient (AHRQ-OP) group.

For this study, an “event” wasdefined as any type of error, mistake,incident, accident, or deviation,regardless of whether or not it resultsin patient harm. “Patient safety” wasdefined as the avoidance and preven-tion of patient injuries or adverseevents resulting from the processes ofhealthcare delivery, and “work unit”or “unit” was defined as the workarea, department, or practice settingin which the respondent spends mostof his or her work time or providedthe most clinical services.

Data Collection and Analysis In April 2014, an email was sent

to all ANNA members inviting themto participate in the online study.Electronic data collection occurredover a one-month period.

Frequencies and means were cal-culated for all quantitative items. Thequalitative data were reviewed byboth researchers and mined forthemes. In addition, for the AHRQitems, a percent positive score wascalculated in order to compare theresults of this study with the data inthe AHRQ Comparative Databases.For positively worded items, the per-cent positive response is the combinedpercentage of respondents who ans -wered “Strongly agree” or “Agree,” or“Always” or “Most of the time,”depending upon the response cate-gories for the item. For negativelyworded items, the percent positiveresponse is the combined percentageof respondents within a hospital whoanswered “Strongly disagree” or“Disagree,” or “Never” or “Rarely;” anegative answer on a negative itemsequals a positive response.



Table 1Patient Safety Culture Dimensions and Definitions

Patient Safety Culture CompositeCronbach’s

a Definition: The extent to which…

Hospital Survey

Communication openness 0.72 Staff freely speak up if they see something that may negatively affecta patient and feel free to question those with more authority.

Feedback and communication abouterror

0.78 Staff are informed about errors that happen, given feedback aboutchanges implemented, and discuss ways to prevent errors.

Frequency of events reported 0.84 Mistakes of the following types are reported: 1) mistakes caught andcorrected before affecting the patient, 2) mistakes with no potential toharm the patient, and 3) mistakes that could harm the patient but donot.

Handoffs and transitions 0.80 Important patient care information is transferred across hospital unitsand during shift changes.

Management support for patient safety 0.83 Hospital management provides a work climate that promotes patientsafety and shows that patient safety is a top priority.

Nonpunitive response to error 0.79 Staff feel that their mistakes and event reports are not held againstthem and that mistakes are not kept in their personnel file.

Organizational learning – Continuousimprovement

0.76 Mistakes have led to positive changes and changes are evaluated foreffectiveness.

Overall perceptions of patient safety 0.74 Procedures and systems are good at preventing errors and there is alack of patient safety problems.

Staffing 0.63 There are enough staff to handle the workload and work hours areappropriate to provide the best care for patients.

Supervisor/manager expectations andactions promoting safety

0.75 Supervisors/managers consider staff suggestions for improvingpatient safety, praise staff for following patient safety procedures, and do not overlook patient safety problems.

Teamwork across units 0.80 Hospital units cooperate and coordinate with one another to providethe best care for patients.

Teamwork within units 0.83 Staff support each other, treat each other with respect, and worktogether as a team.

Medical Office Survey – Additional Components

Office processes and standardization 0.77 The office is organized, has an effective workflow, has standardizedprocesses for completing tasks, and has good procedures for check-ing the accuracy of the work performed.

Patient care tracking/follow up 0.78 The office reminds patients about appointments, documents how wellpatients follow treatment plans, follows up with patients who needmonitoring, and follows up when reports from an outside provider arenot received.

Staff training 0.80 The office provides staff with effective on-the-job training, trains staffon new processes, and does not assign staff tasks they have notbeen trained to perform.

Work pressure and pace 0.76 There are enough staff and providers to handle the patient load, andthe office work pace is not hectic.

Organizational leadership 0.76 Organizational leadership actively supports quality and patient safety,places a high priority on improving patient care processes, does notoverlook mistakes, and makes decisions based on what is best forpatients.

Information exchange with other settings 0.90 Accurate and complete information is exchanged in a timely manner.

Sources: AHRQ, 2014a, b.




ResultsA total of 979 individuals res -

ponded to the survey. Of those, 50indicated that they did not work innephrology patient care and wereexcluded from the data analysis.

With regards to primary role, 487(52.4%) identified their primary roleas RN – Direct Care (Staff Nurse),249 (26.7%) Manager/Administrator,84 (9.0%) Educator, and 50 (5.4%)APRN/NP. For primary work unit,480 (51.7%) selected HemodialysisUnit – Chronic, 211 (22.7%) Hemo -dialysis – Acute, and 80 (8.6%)Peritoneal Dialysis Clinic. Of therespondents who provided organiza-tion status information, 52.2% workedin for-profit organizations and 47.8%worked in not-for-profit organiza-tions. Detailed demographic data canbe found in Table 2.

Overall Patient SafetyParticipants were asked to give

their unit an overall grade on patientsafety using a 5-point Likert scale withthe anchors failing and excellent (seeTable 3). Twenty-six percent (26%) ofthe respondents rated their unit excel-lent, and 51% rated it very good. Inaddition, participants were asked togive an overall rating to the systemsand processes their work unit has inplace to prevent, catch, and correctproblems that have the potential toaffect patients. The ratings were 16%excellent, 42% very good, 28% good,11% fair, and 3% poor.

Respondents working in outpa-tient hemodialysis units and peri-toneal dialysis units were asked if theywould recommend their unit as safe.When asked to indicate their agree-ment with the statement “I would tellmy friends that this is a safe hemodial-ysis/peritoneal dialysis unit for theirfamily,” 34% of the nurses working inOP HD units and 62% of the nursesworking in PD units strongly agreed,and 45% in OP HD units and 29% inPD units agreed (see Table 4).

Four additional items related tooverall perceptions of patient safety(see Figure 1). There was strong agree -ment (19%) and agreement (39%) tothe statement “Patient safety is never

Table 2Demographic Information

Total Respondents 979

Respondents who are not RNs working in nephrology patient care 50

Total respondents in final sample 929

Primary Role

Manager/administrator 249 (26.8%)

RN – Direct care (staff nurse) 487 (52.4%)

APRN/NP 50 (5.4%)

Educator 84 (9.0%)

Other 46 (5.0%)

No response 13 (1.4%)

Primary Work Unit

Hemodialysis unit – Chronic 480 (51.7%)

Hemodialysis – Acute 211 (22.7%)

Nephrology inpatient unit/transplant unit 15 (1.6%)

Peritoneal dialysis clinic 80 (8.6%)

Outpatient clinic 37 (4.0%)

Medical office 13 (1.4%)

Other 79 (8.5%)

No response 13 (1.4%)

Organization Status

For profit 52.2%

Not for profit 47.8%

Experience

Years as a registered nurse 24.53

Years as a nephrology nurse 18.22

Table 3Overall Grades: Patient Safety, Systems and Processes

Excellent Very Good Acceptable Poor Failing

Please give your unit an overall grade on patient safety.

NNPS – All 26% 51% 20% 3% 0%

AHRQ Hospital 2014 33% 43% 19% 4% 1%

Overall, how would you rate the systems and processes your unit has in placeto prevent, catch, and correct problems that have the potential to affect patients.

Excellent Very Good Good Fair Poor

NNPS – All 16% 42% 28% 11% 3%

Note: NNPS – All includes respondents working in all nephrology nurse practice set-tings. AHRQ Hospital 2014 includes data from the AHRQ HSPSC ComparativeDatabase.



sacrificed to get more work done,”resulting in a positive response of58%. This is a lower positive scorethan that of the AHRQ – Hospitalgroup (64%). There was strong agree-ment (13%) and agreement (62%) tothe statement “Our procedures andsystems are good at preventing errorsfrom happening,” a 75% positivescore (compared to the AHRQ –Hospital score of 73%). However, 3%strongly agreed, and 18% agreed withthe statement “We have patient safetyproblems in this unit,” and 5% andstrongly agreed and 18% agreed withthe statement “It is just by chance thatmore serious mistakes don’t happenaround here.”

The open-ended questions yield-ed many positive comments aboutthe general safety culture of the workenvironment. Many nephrology nurs-es described working in an environ-ment that had a strong focus onpatient safety and sound systems inplace. A nurse reported, “We have aprogram in place to identify potentialrisks and try to prevent errors beforethey happen, and we have quarterlysafety meetings.” Other nurses report-ed having daily safety huddles andexisting safety zones on the unit.

Communication, Feedback,And Error Reporting andResponse

Several questions focused onfeedback and communication abouterrors, response to errors, and com-munication openness (see Figures 2,3, and 4). To the statement “Staff willfreely speak up if they see somethingthat may negatively affect patientcare,” 23% said always, and 44% saidmost of the time (67% positive res -

ponse). This is less than the AHRQ –Hospital positive response of 76%.Regarding feedback and communica-tion about errors, 60% respondedpositively to the statement “We areinformed about errors that happen onthis unit.” This was less than the 67%positive AHRQ 2014 Hospital data.Further, 51% responded positively tothe statement “We are given feedbackabout changes put into place based onevent reports.” This again is a lowerrating than the 59% positive responsein the AHRQ comparative data.When asked if staff members feel free

to question the decisions or actions ofthose with more authority, there wasa large difference in the responses ofthe nephrology nurse managers/ad -mi nistrators (75% positive responses)and RNs who are direct careproviders (42% positive responses).

Event reporting is critical to rec-ognizing safety issues and preventingand mitigating patient harm in thefuture. When asked how often theyhad filled out and submitted reportsin the past 12 months, 24% said none,and 30% said they had submitted oneto two events. However, the reporting

Table 4Recommending Their Unit

Strongly Agree

(%)Agree

(%)Neither

(%)Disagree

(%)

Strongly Disagree

(%)

I would tell my friends that this is a safe hemodialysis fortheir family.

34 45 12 7 2

I would tell my friends that this is a safe peritoneal dialysisunit for their family.

62 29 9 0 0

0% 20% 40% 60% 80% 100%

We have patient safety problems in this unit.*

It is just by chance that more serious mistakes don’t happen around here.*

Our procedures and systems are good at preventing errors

from happening.

Patient safety is never sacrificed to get more

work done.

Strongly Agree Agree Neither Disagree Strongly Disagree

Percentage

3%5%

13%

19%

39%

16%

23%

62%

15%

2%3%

8%

18%

14%

39%

24%

17%

16%

42%

21%

Figure 1Overall Perception of Patient Safety

*Negatively worded item.




varies by type of event (see Figure 4).Mistakes that are caught and correct-ed before affecting the patient (nearmisses) or that have no potentialharm to the patient are reported lessoften.

The response to errors influenceshow often errors are reported. Justover 20% of the respondents eitheragreed or strongly agreed that theyfelt like their mistakes were heldagain them, and felt like when anevent was reported, the person wasbeing written up rather than the event(see Figure 5).

In addition to this quantitativedata, the most common concern relat-ed to patient safety reported in theopen-ended questions overwhelming-ly stemmed from a perceived under-reporting of events and near misses.There were several rationales provid-ed for this perceived under-reportingby nurses and patient care techni-cians, including lack of time, cumber-some documentation systems, lack ofmanagerial support or follow up to areported event, and actual or per-ceived punishment toward theemployee reporting an event. Oneparticipant shared, “Documentationof adverse events is cumbersome anddifficult, leading the staff to not com-plete all properly.” Another nursestated, “We have event reporting sitesavailable, but it is difficult to get thetime to enter events or near misses.”While another participant said, “I feelnear misses are under-reported, andthere should be more emphasis andeducation regarding reporting.”Many nurses shared experiences witha punitive system after reporting anevent or near miss, and other nursesdescribed fear of a punitive systembased upon a toxic work environ-ment.

TeamworkTeamwork within units was highly

rated (see Figure 6). In fact, the threehighest rated items in the survey wereteamwork-related: “There is a goodworking relationship between staff andproviders,” “People support one anoth-er in this unit,” and “When a lot ofwork needs to get done quickly, we

0% 20% 40% 60% 80% 100%

Staff are afraid to ask questions when something

does not seem right.*

Staff feel free to question decisions or actions of those

with more authority.

Staff will freely speak up if they see something that may negatively affect patient care.

Staff are willing to report mistakes they observe

in this unit.


Percentage

2%

15%

23%

18%

39%

12%

30%

1%

44%

24%

8% 1%

37%

28%

15%

5%

9% 26%

43%

19%

Figure 2Communication Openness


0% 20% 40% 60% 80% 100%

In this unit, we discuss ways to prevent errors

from happening.

We are informed about errors that happen in

this unit.

We are given feedback about changes put into place

based on event report.


Percentage

24%

14%

37%

15%

31%

3%

36%

26%

12%

2%

29%

24%

36%

9% 2%

Figure 3Feedback and Communication About Error




work together as a team to get the workdone.” When asked about people sup-porting one another on the unit, 85% ofnephrology nurses agreed or stronglyagreed, similar to the AHRQ result of86%. Teamwork across units in hospi-tals is rated slightly lower, but higherthan the AHRQ-Hospital comparativedata (see Figure 7).

Staffing Regarding staffing, only 61% of

the respondents agreed or stronglyagreed that their unit has enough staffmembers to handle the workload (seeFigure 8). In another item, 12% of therespondents strongly agreed, and34% agreed with the statement “Ioften feel rushed when taking care ofpatients.” The overuse of agency/temporary personnel is much less ofan issue in nephrology nurse practicesettings than in hospitals in general.Many nurses shared concerns aboutstaffing numbers and trends in theirpractice setting. The identifiedthemes included lack of registerednurses in the outpatient hemodialysissettings, long hours of the acute dialy-sis nurse, and management of patientswith multiple health problems. Nurs -es reported concerns about decreas-ing staffing numbers in the nephrolo-gy practice settings and the impact onthe quality of care delivered andpatient safety. A nurse shared, “Weare working too long with not enoughstaff, and we are so busy.” Anothernurse said that there needs to be anurse-to-patient ratio law for hemo -dialysis because she is concernedabout the unsafe environment caringfor 20 patients and the potentialimpact this may have on her license ifshe makes a mistake. A nurse work-ing in an acute hemodialysis unitreported that being responsible fortwo patients on dialysis with no back-up staff was too much, as there was noone to answer phone calls, make callsto the physicians, focus on isolationrequirements, assist with computercharting, or allow time for a bath-room break. Regarding patient acuityand staffing, a nurse stated, “Often thepatients in outpatient clinics are olderand have multiple health problems;

0% 20% 40% 60% 80% 100%

Staff worry that mistakes that are made are kept in

their personnel file.*

When an event is reported, it feels like the person is

being written up.*

Staff feel like their mistakes are held against them.*


Percentage

4%4% 19

%

39%

22%

17%

18%

18%

44%

16%

4% 26%

20%

41%

9%

Figure 4Nonpunitive Response to Errors


0% 20% 40% 60% 80% 100%

When a mistake is made that could harm a patient, but does not, how often

is this reported?

When a mistake is made, but has no potential harm to the patient, how often

is this reported?

When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?


Percentage

16%

15%

33%

20%

25%

6%

36%

26%

19%

4%

26%

22%

39%

10%

2%

Figure 5Frequency of Events Reported





lower staff/patient ratios does nothelp with patient safety in my opin-ion.”

Processes and Standardization The results indicated an overall

positive rating for staff members fol-lowing standardized processes and forunits having good procedures forchecking that work is done correctly(see Figure 9). There do appear to be

some issues with workflow and organ-ization. In the open-ended questions,nurses reported having many respon-sibilities and not enough time todeliver care and check the work of thepatient care technicians in the outpa-tient settings. Issues identified includ-ed incorrect weights, incorrect dialy -sate, blood pressures being missed,and poor communication with theregistered nurses. A respondent sug-

gested that focus should be placed onlow frequency and high-risk proce-dures more often than annually. Themost common issue described wasstaff taking short cuts to complete atask within a desired timeframe.Many nurses, however, reportedworking in an environment withexcellent safety programs and poli-cies and procedures in place.

Organizational Learning And Staff Training

On the whole, organizationallearning was rated positively, includ-ing mistakes leading to positivechange (see Figure 10). Staff beingtrained when new processes are putinto place was also rated high (seeFigure 11). There were several com-ments regarding training and educa-tion of new and existing staff mem-bers in general, and also related tosafety protocols and practices. Onenurse stated that education at her unitwas ongoing. This was a commontheme found in many narratives, inaddition to the insight by manyrespondents that education pertainingto safety needs to be ongoing.

Handoffs and TransitionsHandoffs in nephrology nurse

practice settings were a major con-cern just as they are in other health-care settings (see Figures 12 and 13).Forty-nine percent (49%) agreed orstrongly agreed that things “fallthrough the cracks” when patients areadmitted to the hospital, and 61%agreed or strongly agreed that thingsfall through the cracks when patientsare discharged from the hospital tothe hemodialysis unit. Finally, 52%agreed or strongly agreed there is anissue with the exchange of informa-tion between the hospital and thedialysis unit. There were also manyissues related to transfer of informa-tion, including the exchange andavailability of accurate, complete, andtimely information (see Tables 5, 6,and 7). In the area of communication,nurses working in the hospital settingwere asked to answer questionsregarding handoffs. These data indi-cate handoffs between hospital and

0%20% 40% 60% 80% 100%

Teamwork is emphasized when taking care of patients.

In this unit, there is a good working relationship

between staff and providers (physicians, NPs, PAs).

When a lot of work needs to get done quickly, we work

together as a team to get the work done.

Staff feel like they are part of a team.

People support one another in this unit.

In this unit, people treat each other with respect.

When one area of this unit gets really busy,

others help out.


Percentage

24%

32%

20%

30%

55%

7% 6%

56%

14%

2%2%

32%

54%

8% 5% 1%

21%

57%

12%

9% 2%

18%

56%

15%

10%

1%

8%

54%

8% 6% 1%

56%

11%

8% 1%

Figure 6Teamwork within Units




dialysis facilities are areas that requirefurther investigation.

Management and LeadershipSupport for Patient Safety

Across the board, supervisor andmanager expectations and actionspromoting and supporting patientsafety and support for patient safetyby organizational leadership wererated lower than comparative datafrom AHRQ (see Figures 14, 15, and16). For example, when asked if man-agement/leadership provides a workclimate that promotes safety, directpatient care nephrology nurses re -ported a 66% positive response, whilethe AHRQ positive response was81%. Moreover, 35% agreed orstrongly agreed with the statement“My organization’s management/leadership makes decisions based onwhat is best for the organizationrather than what is best for patients.”This was the second lowest-rated itemin the entire survey. A commonlymentioned issue in the open-endedquestions was a strengthening focuson productivity and weakening focuson patient centered care. Many nurs-es commented that the dialysis organ-ization and management focus on abottom line that pushes the staff to getthe patients on and off the hemodial-ysis machine as quickly as possible, sothe equipment can be turned over forthe next patient to use. It was clearlydescribed by one nurse as “get themin, on, and gone,” and this leads torushing and incomplete work.

0%20% 40% 60% 80% 100%

We have too many patients for the number of providers

on this unit.*

I often feel rushed when taking care of patients.*

Staff in this unit work longer hours than is safe

for patient care.*

We work in “crisis mode” trying to do too much,

too quickly.*

We use more agency/temporary staff than is best for patient care.*

We have enough staff to handle the workload.


Percentage

7%12

%8% 25

%

19%

36%

34%

17%

6%12

%

1% 4% 14%

28%

54%

8% 23%

16%

38%

14%

16%

45%

8% 24%

7%

31%

18%

17%

44%

15%

Figure 8Staffing


Table 5Information Exchange with other Settings

Over the past 12 months, how often hasyour hemodialysis unit had problemsexchanging accurate, complete, and timelyinformation with

Daily(%)

Weekly(%)

Monthly(%)

Several Times in the Past

12 Months (%)

Once or Twice in the Last

12 Months(%)

None in the Past

12 Months(%)

Outside labs/imaging center? 1 2 5 21 29 42

Other medical offices/outside physicians? 1 4 5 24 33 34

Pharmacies? 1 3 6 16 28 46

Hospitals? 2 8 10 21 28 32

Emergency departments? 1 4 6 15 26 47

Note: Totals may not equal to 100% due to rounding.




Specific Patient Safety IssuesThere were several items pertain-

ing to specific patient safety issues.When asked how often in the last 12months a wrong drug or wrong dose(including wrong dialysate dose) wasadministered, 1% said daily, 6% saidweekly, and 6% said monthly. Nursesshared several stories about medica-tion errors occurring on the unit orupon discharge from the hospital.Some issues were grounded in obtain-ing the wrong orders related to poorhandoff procedures, lack of a medica-tion reconciliation during hospitaliza-tion and upon discharge to an outpa-tient setting, or an error due to othersystem procedures or documentationprograms. Some nurses shared theenforcement of new policies relatedto timing of medication reconciliationand new electronic medical recordsystems that decreased the incidenceof medication errors. Other nursesreported medication reconciliationand administration errors remainunresolved.

When asked to indicate theiragreement with the statement “Staffin the hemodialysis unit/peritonealdialysis unit wash their hands imme-diately after removing gloves,” only14% of the nurses working in OP HDunits strongly agreed, and 54%agreed (see Figure 17). For nursesworking in PD units, 53% stronglyagreed and 35% agreed. Infectioncontrol was a common concernamong participants in the narratives,and it was often attributed to lack ofknowledge, time, and attention toprotocols. It was reported in one unitthat patient safety was good overall,but staff were not following infectionguidelines and failed to wear gloveswhen resetting machine alarms.Another nurse reported observingcoworkers skipping infection controlpractices when they think they wouldnot get caught. Yet another nurserecounted staff not wearing personalprotective equipment in a hepatitis Bpositive isolation room

Many respondents identified fallsin nephrology nurse practice settingsas an issue. Several nurses recountedstories of changes in policies thatrequired a staff member to accompa-ny a patient to the bathroom or scale,and keeping patients at risk for fallingin the dialysis unit until transportationarrives. A nurse working in a hospitalnephrology unit reported that hourlyrounding and use of call bells de -creased patient falls.

Best PracticesOn the positive side, many nurs-

es reported working in an environ-ment with a strong focus on patientsafety and sound safety systems inplace. A nurse reported, “We have aprogram in place to identify potentialrisks and try to prevent them beforethey happen, and we have quarterlysafety meetings.” Another nurseshared, “We have a Just Culture teamthat encourages reporting of nearmisses or problems before they canbecome an issue or event, and thishas brought to light many things.”Nurses reported holding safety hud-dles daily or having safety zones onthe unit. Nurses also reported open-ness to errors and follow-through bymanagers when issues are reported inthe presence of a non-punitive sys-tem. Many nurses reported that safetywas the number one priority on theunit. Finally, there were reports ofeffective documentation systems thatcollected data on events and nearmisses and sent the data to managersand administrators for analysis andfollow-up action.

LimitationsThere are several limitations to

this study. Likely the greatest limita-tion is the self-selected nature of therespondents to this survey. Because ofthe volunteer nature, it is possiblethese individuals had more exposureto safety in the practice setting or astronger than usual interest in safetypractices and culture. Respondents tothe study may have completed thesurvey after completing a particularlychallenging or simple day at work.

0% 20% 40% 60% 80% 100%

Staff take shortcuts to get their work done faster.*

The unit is more disorganized than it should be.*

Staff follow standardized processes to get work done.

We have problems with workflow in this unit.*

We have good procedures for checking that work was

done correctly.


Percentage

6%6%

15%

12%

55%

15%

16%

2%

5% 26%

41%

18%

10%

66%

11%

8% 1%

21%

12%

43%

18%

29%

15%

38%

12%

Figure 9Processes and Standardization




This may have resulted in responsesthat reflected the recent level of chal-lenge or simplicity in the work envi-ronment. Further, there is no way toascertain if the respondents trulyunderstood the content of the ques-tion. Misinterpretation of the posedquestion may have led to an inaccu-rate response.

Discussion The overall response rate to this

survey indicates nephrology nurseshave an interest in patient safety prac-tices and culture. This noted interestwas also evidenced by the numerousand sometimes lengthy narrativesprovided by the respondents. Uponinitial review of the data, it appearedmany items received ratings that werecomparable to the AHRQ ratings.Yet, upon further investigation of thepercentage of positive responses forindividual items, safety issues werepresent. Such issues include handoffs,infection control, medication errors,communication, prioritization, staf -fing, and workload. These data indi-cate a continued need for additionalfundamental education related tohand hygiene, medication administra-tion safety, communication, and pri-oritization in practice settings. In fact,these are areas open to research andeducation in nephrology nurse prac-tice settings because these principalsare core elements in nursing educa-tion programs and safe practice. Ad -ditional investigation needs to occurto determine the factors that are con-tributing to the underperformance ofbasic nursing skills. The respondentsindicated a perceived need to rush tocomplete tasks in the dialysis unitresulting in incomplete work. Theseperceptions may play a key role inthis under-performance of basic nurs-ing skills. Investigation is needed todetermine whether the systems inplace encourage rushing or if it self-directed by the nephrology staff.

Teamwork items received a highpercentage of positive scores fromrespondents. The nature of the workperformed in nephrology practice set-tings has long required teamwork and

0% 20% 40% 60% 80% 100%

After we make changes to improve patient safety, we

evaluate their effectiveness.

Mistakes have led to positive changes here.

We are actively doing things to improve patient safety.


Percentage

13%

24%

55%

6%14%

1%

57%

20%

7% 2%

12%

17%

57%

13%

1%

Figure 10Organizational Learning – Continuous Improvement


0% 20% 40% 60% 80% 100%

Staff are trained when new processes are put into place.

Staff are asked to do tasks they have not been trained to do.*


Percentage

17%

2% 10%

52%

8% 28%

59%

10%

11%

2%

Figure 11Staff Training





interprofessional collaboration forsuccessful delivery of holistic patientcare to patients with complicated dis-ease processes and care needs.

Two areas were recognized inwhich there were differences in rat-ings. It was noted that managers/administrators consistently rated thepatient safety culture higher thandirect care nephrology nurses. Thesefindings are consistent with findingsreported by Singer and colleagues(2009). They studied the relationshipbetween patient safety culture andpatient safety indicators in 91 hospi-tals. Singer and colleagues (2009)observed that senior managementmight not fully appreciate the safetyhazards of their organization. In thisstudy, respondents in not-for-profitorganizations rated the patient safetyculture higher than respondents infor-profit organizations. Data fromnot-for-profit and for-profit organiza-tions and the differences in responsesof direct care nurses and managers/administrators will be published infuture articles.

Table 6The following items describe things that can happen in healthcare settings that affect patient safety

and quality of care. In your best estimate, how often did the following things happen in your unit over the past 12 months?

Daily(%)

Weekly(%)

Monthly(%)


12 Months(%)


12 Months(%)

None in the Past

12 Months(%)

A patient was unable to get an appointment/care within 48 hours for an acute/seriousproblem.

1 2 3 13 23 58

A wrong chart/medical record was used for apatient.

0 0 0 4 20 76

A patient’s chart/medical record was notavailable when needed.

1 1 1 8 14 74

Medical information was filed, scanned, orentered into the wrong patient’s medical record.

0 1 2 12 36 49

Medical equipment was not working properly orwas in need of repair or replacement.

5 12 10 24 26 24

A wrong drug or wrong dose was administeredto a patient (including dialysate solutions).

1 6 6 17 36 35


0% 20% 40% 60% 80% 100%

Problems often occur in the exchange of information between the hospital and the hemodialysis unit.*

Things “fall between the cracks” when patients are

discharged from the hospital to the unit.*

Things “fall between the cracks” when patients are admitted to the hospital.*

Things “fall between the cracks” when patients go to the emergency room.*


Percentage

13%

16%

10%

8% 38%

17%

32%

38%

17%

6%5%

29%

44%

12%

22%

5%

39%

16%

28%

4%

Figure 12Handoffs and Transitions – Nephrology Nurse

Practice Setting – Hospital




Analysis of the qualitative dataresulted in the identification of severalthemes, including under-reporting ofevents, poor staffing ratios, long workhours, cumbersome documentationsystems, infection control failures,compliance issues with policies andprocedures, inadequate training, andcommunication breakdown. A fullanalysis of the qualitative data will bediscussed in a future publication.

There were many reports of bestpractices in creating and maintainingpatient safety culture. These successstories need to be studied and sharedwith the nephrology community.

It is clear that nurses in all areas ofnephrology practice need to start rou-tinely assessing the culture of safety intheir practice setting. Use of the entiretool employed by the re searchers maybe time-consuming as an initial step,so a short tool with selected AHRQitems is provided in Table 8. It is sug-gested that nephrology nurses use thistool to collect data to initially assessthe patient safety culture in their prac-tice settings and hold interprofessionalmeetings to discuss the findings. Infacilities that may be using a safetydata collection tool, these items maybe integrated into the tool or substitut-ed for similar items.

Table 7How often did the following things happen in your hemodialysis unit over the past 12 months?

Daily(%)

Weekly(%)

Monthly(%)


12 Months(%)


12 Months(%)

None in the Past

12 Months(%)

A pharmacy contacted our unit to clarify or correct aprescription.

6 7 7 28 30 21

A patient’s medication list was not updated during his or hervisit.

2 5 19 29 26 20

The results from a lab test or imaging text were not availablewhen needed.

1 5 8 27 28 31

A critical abnormal result from a lab or imaging test was notfollowed up within one business day.

1 4 8 12 27 49

The patient’s dialysis prescription used for the treatment wasdifferent than that ordered by the primary care provider.

2 4 6 18 26 45

Patients developed infections related to poor practices bystaff.

1 2 4 11 26 56


0% 20% 40% 60% 80% 100%

Problems often occur in the exchange of information between the hospital and the hemodialysis unit.*

Things “fall between the cracks” when patients are

discharged from the hospital to the unit.*

Things “fall between the cracks” when patients are admitted to the hospital.*

Things “fall between the cracks” when patients go to the emergency room.*


Percentage

13%

16%

10%

8% 38%

17%

32%

38%

17%

6%5%

29%

44%

12%

22%

5%

39%

16%

28%

4%

Figure 13Handoff and Transition Issues – Nephrology Nurse Practice Setting –

Outpatient Hemodialysis Unit





Table 8Patient Safety Culture – Mini Assessment – Summary Sheet

Strongly Disagree Disagree Neither Agree

Strongly Agree

Percent Positive Score

Your Unit

Score

AHRQ 2014 Score

NNPS All

Score

1. When a lot of work needs to be done quickly, wework together as a team to get the work done.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

86% 83%

2. My supervisor/manager seriously considers staffsuggestions for improving patient safety.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

77% 71%

3. Mistakes have led to positive changes here. N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

64% 70%

4. After we make changes to improve patient safe-ty, we evaluate their effectiveness.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

71% 69%

5. Management/leadership provides a work climatethat promotes patient safety.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

81% 72%

6. Patient safety is never sacrificed to get morework done.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

64% 58%

7. We have enough staff to handle the workload. N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

54% 60%

8. Staff will freely speak up if they see somethingthat may negatively affect patient care.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

76% 67%

9. Staff are trained when new procedures are putinto place

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

78% 59%

10. Things “fall between the cracks” when transfer-ring patients from one unit/facility to another.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

43% 44%

11. We have good procedures for checking whatwork was done correctly.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

73% 67%

12. Staff in the unit wash their hands immediatelyafter removing gloves.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

67% HD88% PD

13. My organization’s management/ leadershipplaces a high priority pm improving patient careprocesses.

N =% =

N =% =

N =% =

N =% =

N =% =

N=%=

82% 70%

Poor Fair GoodVery Good Excellent

14. Overall, how would you rate the systems andprocesses your work unit has in place to pre-vent, catch, and correct problems that have thepotential to affect patients

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

68% 58%

ExcellentVery Good Acceptable Poor Failing

Please give your unit an overall grade on patientsafety.

N =% =

N =% =

N =% =

N =% =

N =% =

N =% =

76% 77%

Notes: This mini-assessment is designed to be used as a high level initial assessment of patient safety culture in nephrology nurse prac-tice settings in order to begin to identify the safety culture issues in the unit. To use this mini-assessment, create a hard copy or onlinecopy of the tool’s first six columns, removing the “N =” and “% =” from each cell. Have staff members fill out the forms. Count the numberof ratings for each response option in each question. Determine the percent of the total responses for each response option. To obtaina percent of positive scores number that will be comparable to AHRQ results and results from this study (NNPS – All), add the two percentscores in the blue-shaded cells. Enter that information in the green cells. Compare your results (green-shaded cells) to the AHRQ andNNPS-All results. Prioritize the issues identified. Create and implement a plan to prevent and/or mitigate safety issues.



Conclusions and Implications For Nursing

In summary, this inaugural inves-tigation of patient safety culture innephrology nurse practice settingshas yielded a voluminous quantity ofrich data. The number of respondentsto the study far exceeded the expecta-tions of the researchers, and may indi-cate the importance of this issue tonephrology nurses. Further, the nurs-es provided detailed stories andexamples of positive and negativesafety issues occurring in variouspractice settings, again exemplifyingthe significance of this topic.

Patient safety culture needs toremain central to quality initiatives inthe hospital and outpatient settings.Nephrology nurses are in a uniqueposition to champion patient safetyculture initiatives in the practice set-ting. Nephrology nurses often havethe opportunity to interact with theirpatients several times a week, thusproviding a level of patient familiarityunparalleled in many other special-ties. Nephrology nurses need to listento the safety concerns and fears of thepatients entrusted to their care. Whilepatient-reported outcomes werebeyond the scope of this study, it is animportant area to consider when eval-uating the patient safety culture.

Open lines of communicationfrom administration to direct carestaff and vice versa are essential ele-ments in the development of a cultureof patient safety that encouragesevent reporting. If such a culture doesnot exist, this needs to be the first stepaddressed. Evidence of this approachis supported by research conductedby Reason and Hobbs (2003). Reasonand Hobbs identified three maincomponents of a safety culture: learn-ing culture, just culture, and reportingculture. “The three components areintertwined – without a just culture,you have minimal reporting; withoutreporting, you have no opportunitiesto learn and improve.” (Ulrich &Kear, 2014, p. 450). Interprofessionalcollaboration and quality improve-ment meetings provide a vehicle toopening lines of communication todiscuss the culture of patient safety.

0% 20% 40% 60% 80% 100%

My supervisor/manager overlooks patient safety problems that happen

over and over.*

Whenever pressure builds up, my supervisor/manager wants us to work even faster, even if it means taking shortcuts.*

My supervisor/manager seriously considers staff

suggestions for improving patient safety.

My supervisor/manager says a good word when he/she sees

a job done according to established patient procedure.


Percentage

2%2%

18%

16%

50%

15%

13%

53%

14%

5%6%

10%

10%

14%

48%

26%

12%

11%

43%

32%

Figure 14Supervisor/Manager Expectations and Actions

Promoting Patient Safety


0% 20% 40% 60% 80% 100%

Management/leadership seems interested in patient safety only after an adverse

event happens.*

The actions of manage-ment/leadership show that

patient safety is a top priority.

Management/leadership provides a work climate that

promotes patient safety.


Percentage

22%

18%

55%

11%

15%

2%

47%

17%

11%

3%

5% 15%

22%

40%

18%

Figure 15Management Support for Patient Safety





Direct care staff should be invited toquality improvement meetings as wellas any other meetings in which deci-sions about care delivery or care forspecific patients are being discussed.

Processes and documentationsystems for reporting events and nearmisses need to be assessed for effi-ciency and ease of use. Management/administration must analyze the doc-umented safety data, share findingswith staff, and make changes inprocesses that address the identifiedsafety issue. Lack of timely feedbackwas a frustration verbalized bynumerous respondents to this survey.Direct care staff must take the time toshare challenges experienced with re -porting systems with healthcare man-agers in an objective manner.

Each AHRQ dimension requiresfurther study. Direct care nurses andmanagement/administration shouldbecome familiar with the dimensionsof patient safety as an initial step inevaluating the safety culture of the set-ting. If safety culture measures are notbeing used in a specific setting, thenephrology nurse may wish to con-sider using the tool included in thisarticle for initial data collection.Nephrology nurse leaders may alsoconsider contacting a dialysis unit,transplant center, or office setting thathas established a successful patientsafety program. Programs with posi-tive safety culture environments needto share their successes with col-leagues via publications and presenta-tions. This study revealed many suc-cess stories and much work yet to beaccomplished. Nephrology nurses arewell poised to carry this work forwardto meet the most basic of needs,which is maintaining and protectingthe safety of our patients.

References Agency for Healthcare Research and

Quality (AHRQ). (2014a). Hospitalsurvey on patient safety culture: 2014 usercomparative database report. Rockville,MD: Author. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html

0% 20% 40% 60% 80% 100%

My organization’s management/leadership make decisions based

on what is best for the organization rather than what is best

for the patients.*

My organization’s management/leadership places a high priority on improving patient care processes.

My organization isn’t investing enough resources to improve the quality of care in this unit.*


Percentage

11%

7% 21%

37%

15%

20%

24%

46%

11%

16%

3%

24%

22%

31%

11%

Figure 16Organizational Leadership Support for Patient Safety


0% 20% 40% 60% 80% 100%

Infection control practices are followed per established

unit protocol.

Staff in the hemodialysis unit wash their hands immediately

after removing gloves.

Staff in the peritoneal dialysis unit wash their

hands immediately after removing gloves.

Personal protective equipment (PPE) is worn by staff as

per unit protocols.


Percentage

23%

14%

53%

28%

52%

6% 12%

35%

0%

2%

12%

54%

12%

18%

2%

56%

6% 13%

2%

Figure 17Infection Control




Agency for Healthcare Research and Qua -lity (AHRQ). (2014b). Medical of fice sur-vey on patient safety culture. Rockville,MD: Author. Retrieved fromhttp://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/

Agency for Healthcare Research andQuality (AHRQ). (2014c). Medicaloffice survey on patient safety culture:2014 user comparative database report.Rockville, MD: Author.

Braithwaite, J., Westbrook, M.T.,Travaglia, J.F., & Hughes, C. (2010).Cultural and associated enablers of,and barriers to, adverse incidentreporting. Quality and Safety in HealthCare, 19, 229-233.

Huang, D.T., Clermont, G., Kong, L.,Weissfeld, L.A., Sexton, J.B., Rowan,K.M., & Angus, D.C. (2010). Inten -sive care unit safety culture and out-comes: A US multicenter study.International Journal for Quality inHealth Care, 22(3), 151-161.

Institute of Medicine (IOM). (2000). To erris human: Building a safer health system.Washington, DC: National AcademyPress. Retrieved from http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx

James. J.T. (2013). A new, evidence-basedestimate of patient harms associatedwith hospital care. Journal of PatientSafety, 9(3), 122-128.

Mardon, R.E., Khanna, K., Sorra, J.,Dyer, N., & Famolaro, T. (2010). Ex -ploring relationships between hospi-tal safety culture and adverse events.Journal of Patient Safety, 5, 226-232.

Reason, J., & Hobbs, A. (2003). Managingmaintenance error. Farnham, Surrey,England: Ashgate.

Singer, S., Lin, S., Falwell, A., Gaba, D., &Baker, L. (2009). Relationship ofsafety climate and safety perform-ance in hospitals. Health ServicesResearch, 44(2), 399-421. doi:10.1111/j.1475-6773.2008.00918.x

Sorra, J., Khanna, K., Dyer, N., Mardon,R., & Famolaro, T. (2012). Exploringrelationships between patient safetyculture and patients’ assessment ofhospital care. Journal of Patient Safety,8(3), 131-139.

Ulrich, B., & Kear, T. (2014). Patient safetyand patient safety culture: Foun -dations of excellent health care deliv-ery. Nephrology Nursing Journal, 41(5),447-456, 505.


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