Patient Safety Culture and Nurse-Reported Adverse Events in Outpatient Hemodialysis Units

By Thomas-Hawkins, Charlotte; Flynn, Linda | Research and Theory for Nursing Practice, April 1, 2015 | Go to article overview

Patient Safety Culture and Nurse-Reported Adverse Events in Outpatient Hemodialysis Units


Thomas-Hawkins, Charlotte, Flynn, Linda, Research and Theory for Nursing Practice


Aims: Patient safety culture is an important quality indicator in health care facilities and has been associated with key patient outcomes in hospitals. The purpose of this analysis was to examine relationships between patient safety culture and nurse-reported adverse patient events in outpatient hemodialysis facilities. Methods: A cross-sectional correlational, mailed survey design was used. The analytic sample consisted of 422 registered nurses who worked in outpatient dialysis facilities in the United States. The Handoff and Transitions and the Overall Patient Safety Grade scales of the Agency for Healthcare Research and Quality's (AHRQ) Hospital Patient on Safety Survey were modified and used to measure patient safety culture in outpatient dialysis facilities. Nurse-reported adverse patient events was measured as a series of questions designed to capture the frequency with which nurses report that 13 adverse events occur in the outpatient dialysis facility setting. Results: Handoff and transitions safety during patient shift change in dialysis centers was perceived negatively by a majority of nurses. On the other hand, a majority of nurses rated the overall patient safety culture in their dialysis facility as good to excellent. All relationships between patient safety culture items and adverse patient events were in the expected direction. Negative ratings of handoffs and transitions safety were independently associated with increased odds of frequent occurrences of vascular access thrombosis and patient complaints. Negative ratings of overall patient safety culture in dialysis units were independently associated with increased odds of frequent occurrences of medication errors by nurses, patient hospitalization, vascular access infection, and patient complaints. Conclusion: Findings from this analysis indicate that a positive patient safety culture is an important antecedent for optimal patient outcomes in ambulatory care settings.

Keywords: patient safety culture; hemodialysis; adverse events; quality of care

Avast majority of health care in the United States takes place in outpatient or ambulatory care settings (Agency for Healthcare Research and Quality, 2012). Despite this fact, efforts to improve patient safety have focused largely on inpatient settings, and less is known about safety culture in care settings outside of the hospital. Outpatient hemodialysis centers are a type of ambulatory care setting that is the most common site of long-term hemodialysis therapy for persons with chronic kidney failure. Nearly 90% of persons with this condition in the United States receive hemodialysis treatments three times a week in 6,000 outpatient dialysis centers (United States Renal Data System, 2013). Currently, more than 60 million hemodialysis treatments in outpatient settings are performed annually in the United States. Although hemodialysis in an outpatient setting is a routine mode of treatment, it is a complex and potentially hazardous procedure (Holley, 2010). Moreover, it is well established that there are major gaps in the safety net around this procedure (Himmelfarb, 2010), and there has been little research dedicated to assessing and improving the safety of patients in this critical outpatient setting.

ADVERSE EVENTS IN HEMODIALYSIS PATIENTS

Multiple patient safety risks and adverse events are readily apparent in outpatient hemodialysis units. In the past decade, surveys of dialysis professionals and patients that focused on safety issues in dialysis units revealed these outpatient settings share important patient safety risks including patient falls, medication errors, failure to follow established policies, errors in dialysis machine preparation, lapses in infection control, vascular access-related events, excess blood loss/prolonged bleeding, and lapses in communication (DeVivo, 2001; Renal Physicians Association, 2007). In addition, a review of adverse events in four outpatient hemodialysis units during an 18-month period revealed a total of 88 events over this time span, including infiltration of the vascular access, medication errors, dialysis circuit clotting, and falls in the dialysis unit after the treatment (Holley, 2006). …

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