Keeping Patients Safe: A Fundamental Requirement to Move Up the Clinical Quality Pyramid

I was having a conversation with my mother-in-law, Doris, recently at her assisted-living facility. She had moved from her own apartment to the memory-care unit two years prior and had adjusted well to the smaller space and more institutional structure of the care she was receiving. At 92 years old she was fortunate to be physically frail but otherwise healthy—on only Synthroid for long-standing hypothyroidism. Slowly progressive dementia is apparent, but she is still able to carry out activities of daily living and recognize and enjoy visitors. I had recently completed Atul Gawande’s newest book, “Being Mortal: Medicine and What Matters in the End,” and decided to ask Doris what mattered most to her at this stage in her life. She wanted to be treated compassionately, with dignity, and she wanted to feel safe as her external environment contracted around her.

She wanted to feel safe. How many of us as physicians have asked our patients what is important to them? How many of our patients would say they want to feel safe when undergoing a complex technical medical treatment 156 times per year, year after year? My guess is many of them would express this as a concern. Years ago the Renal Physicians Association took on this issue and surveyed dialysis facilities about common safety issues, and then developed the Keeping Kidney Patients Safe website to help educate professionals and patients about this topic. Key areas of focus are proper dialyzer and dialysate use, proper administration of medications, avoiding falls in the dialysis facility and at home, proper hand hygiene, avoiding needle dislodgements and following all policies and procedures as written.

This list of very specific areas of patient safety in the dialysis setting is consistent with the national movement in health care in this area. On July 29, 2005, President Bush signed the Patient Safety and Quality Improvement Act to encourage voluntary and confidential reporting of adverse health care events. Toward that goal, the act authorized the creation of Patient Safety Organizations to collect related data and maintain appropriate confidentiality. Both DaVita Kidney Care and Fresenius Medical Care have such organizations focused on improving quality and safety of care. In addition, the Joint Commission accreditation process for various health care settings includes evaluation of efforts to improve patient safety. Although the specifics vary somewhat depending on the site of care, key areas include proper identification of patients and matching treatments/medications to the right patient, appropriate medication administration, prevention of infection, prevention of falls and identification of other safety risks.

At the end of the day, however, optimal patient safety will be achieved only if organizations, including dialysis facilities, are successful in creating a culture of safety. This concept began outside of health care in industries such as commercial airlines, characterized (like dialysis) as ones where the work is complex and potentially hazardous. The key components of establishing the culture of safety according to the AHRQ Patient Safety Network include the following:

• Acknowledgement 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

To successfully develop a culture of safety in any organization requires focused commitment at all levels. In dialysis this includes corporate facility owners or independent owners/operators, medical directors and all members of the interdisciplinary care team. As articulated by the Institute for Healthcare Improvement, “In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed. Inaction in the face of safety problems is taboo.… There is no room in a culture of safety for those who uselessly point fingers or say, ‘Safety is not my responsibility, so I’ll file a report…’. Even so, an organization can improve upon safety only when leaders are visibly committed to change and when they enable staff to openly share safety information.”

So in this National Kidney Month of 2015 let us all commit to creating a culture of safety in our organizations. It is the right thing to do for our patients, as it is for all of the vulnerable, the frail, the chronically ill, and those like my mother-in-law, who deserve compassionate, safe care.

We could all learn from Sir Liam Donaldson, a British physician, chancellor of Newcastle University and former chief medical officer for England, who said,

“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.… You wouldn’t just decide to forget about recovering the black box after an air crash. So why should it be thought so strange to want to learn from every accident in health care?”