January 17, 2012
Establishing the Culture of Safety in Dialysis
We have to admit — we are coming late to the party! The concept of a culture of safety began outside of healthcare in organizations that self-characterized as “high reliability,” where highly complex and often hazardous activities are a daily reality. Such organizations live and breathe safety from the senior executives to the frontline workers. The Agency for Healthcare Research and Quality (AHRQ) suggests that the following are key features of a successful culture of safety:1
- Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
- A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
- Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
- Organizational commitment of resources to address safety concerns
There are national efforts ongoing outside of AHRQ to address safety in healthcare, most notably the National Patient Safety Foundation (NPSF).2 This independent, nonprofit organization was established in 1997 and continues to provide programs to assist organizations in focusing on safety in healthcare. In 2006, a survey was conducted, led by the Renal Physicians Association (RPA), to get insights from patients and professionals on the state of patient safety knowledge and programs in ESRD/dialysis. This effort culminated in an ongoing website, Keeping Kidney Patients Safe, which is a fantastic resource in this area.3
Through the survey mentioned above, key areas of focus were identified, including hand hygiene, patient falls, incorrect dialyzer or solution, medication omissions or errors, non-adherence to procedures and venous needle dislodgement. Clearly, these are important issues of patient safety, and there are likely others that need attention as well. Missing from this list, however, are provider safety issues such as needle punctures. With the shrinking workforce in dialysis, keeping our colleagues in the dialysis facility safe is also an important imperative.
So, how do we implement the culture of safety in our facilities? By making a commitment as nephrologists and medical directors to make this a core part of how we function. The American Association of Kidney Patients (AAKP) has tried to get the patients involved in the effort with their national program, 5 Steps to Safer Health Care, described by Dr. Alan Kliger:4
- Speak up if you have questions or concerns
- Keep a list of all of your medications
- Make sure you get the results of any test or procedures
- Talk with your doctor and healthcare team about your options
- Make sure you understand what will happen if you need surgery
We need to make a commitment as we enter 2012: Establishing a culture of safety in our facilities will be a great gift for our patients and our staff, and we will make it happen! To do this successfully will require reassessment of the systems of care we currently have and a willingness to make the necessary changes.
As recently stated by Dr. Paul Batalden (and possibly attributable to W. Edwards Deming and/or Donald Berwick) of Dartmouth Medical School and the Institute for Healthcare Improvement (IHI):
“Every system is perfectly designed to get the results it gets.”
I look forward to your comments, until next time.
Striving to bring quality to life,
Allen R. Nissenson, MD
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References:
1. http://psnet.ahrq.gov
2. http://www.npsf.org
3. http://www.kidneypatientsafety.org
4. http://www.aakp.org
Petter Olsson said,
January 18, 2012 @ 7:55 am
It was exciting to see this post from DaVita making a stand in regards to patient safety in dialysis, recognizing RPA’s program Keeping Kidney Patients Safe as a fantastic resource. Knowing the risks involved with Venous Needle Dislodgements, the statement of how to implement the culture of safety in our facilities “By making a commitment as nephrologists and medical directors to make this a core part of how we function” and “We need to make a commitment as we enter 2012”, it certainly sounds promising that change is happening.
With growing patient populations in both Home HD and Nocturnal HD, we are looking forward to the next steps taken by DaVita to help prevent and detect the preventable complication Venous Needle Dislodgement. In particular when this is happening in a time of a “shrinking workforce in dialysis”, consequently less caretakers available to visually monitor and react to complications.
Thanks,
Petter Olsson
Redsense Medical Inc
Jane Hurst, RN, CLNC said,
January 19, 2012 @ 3:33 am
Dr. Nissenson, It is refreshing to read that you are committed to establishing a culture of safety within DaVita. Healthcare safety organizations have worked diligently for years to raise awareness of the weak links in the chain of safe patient care. But the only way we will see improvements is when everyone is working together on a common goal. Speaking from a medical-legal perspective; it has been my experience that many instances of poor outcomes in patient care are directly related to the issues identified by the AHRQ. Short staffing, errors made by staff that are not revealed for fear of punishment, lack of continuity of care, and not utilizing available safety devices because of the expense, are themes I frequently see. I sincerely hope that your commitment to a Culture of Safety in dialysis is more than just words.
Allen Nissenson said,
January 19, 2012 @ 8:23 am
You have rightfully pointed out that ensuring patient safety requires a commitment from the highest levels of the organization to the teammates working in the field. We have made such a commitment and will be working hard going forward to walk the walk!
Nancy Armistead said,
February 1, 2012 @ 11:05 am
Allen,
I wonder if you are aware of the 5 Diamond Patient Safety Program that 12 of the ESRD Networks now participate in. This program was designed originally by Networks 5 & 1 to promote a culture of patient safety in the dialysis centers and many providers (including DaVita) have been through the program. A facility obtains a diamond for each module completed and receives rewards (such as a certificate, free registration at meetings) for obtaining 5 diamond status. The website for additional information is 5diamondpatientsafety.org.
Regards,
Nancy
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