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

1
Patient Safety Culture and Nurse-Reported Adverse
Patient Events in Outpatient Hemodialysis
Facilities

• Charlotte Thomas-Hawkins, PhD, RN
• Linda Flynn, RN, PhD, FAAN

2
Adverse Events in Outpatient Dialysis Facilities

• Common occurrence (Holly, 2006)
• 88 adverse events in 4 month period in 4 HD units
• Falls
• Infiltration of vascular access
• Medication errors
• International variations (Saran et al., 2003)
• Increased skipped and shortened dialysis
  treatments in U.S.
• Daily to weekly occurrences (Thomas-Hawkins et
  al., 2008)
• Skipped and shortened dialysis treatments
• Dialysis hypotension
• Patient and family complaints

3
Nursing Organization and Outcomes Model
Aiken et al., 2002
Work Environment Support for Nursing Practice
Nursing Structures RN-to-pt ratios Workload
Patient Outcomes
Process of Care Care Left Undone
4
Effects of nursing variables on odds of weekly
to daily occurrences of adverse events
Adverse Event High RN-to-Pt ratios 3 or more care tasks left undone Supportive work environment
Hypotension NS 2.72 0.45
Shortened TX 3.79 2.03 0.27
Skipped TX 2.27 1.92 0.34
Complaints NS 3.00 0.53

p lt.01, p lt.000 Thomas-Hawkins, Flynn, Clarke, 2008 (Adjusted effects)
5
Patient Safety Culture

• Product of individual and group values,
  attitudes, perceptions, competencies, and
  patterns of behavior that determine the
  commitment to, and the style and proficiency of,
  an organizations health and safety management.
• Sorra Dyer, 2010

6
Dimensions of patient safety cultureSorra
Nieva, 2004

• Supervisor/manager expectations actions
  promoting safety
• Hospital management support for patient safety
• Organizational learning, continuous improvement
• Teamwork within and across units
• Communication openness
• Feedback and communication about error
• Nonpunitive response to error
• Staffing
• Handoffs and transitions
• Patient safety grade
• Event reporting

7
Patient Safety Culture

• Negative assessments of patient safety culture is
  associated with higher adverse patient events in
  hospital settings
• Poor to failing safety grade
• Iatrogenic pneumothorax, post-op infections,
  medication errors
• Handoffs and transitions
• AHRQ patient safety indicators, medication errors

8
Handoffs and Transitions Safety

• Transfer process of essential information and
  responsibility for patient care
• Effective handoff supports exchange of critical
  information and continuity of care and treatment
• Ineffective handoffs and transitions associated
  with adverse patient events

9
Handoffs and Transitions in Dialysis Units
10
Nursing Organization and Outcomes Model
Aiken et al., 2002
Work Environment Patient Safety Culture Support
for Nursing Practice
Nursing Structures RN-to-pt ratios Workload
Patient Outcomes
Process of Care Handoffs and Transitions Safety Ca
re left undone
11
Study Purpose

• What percentage of nurses positively endorse
  handoffs and transition safety and overall
  patient safety in outpatient hemodialysis units?
• What are the unadjusted and adjusted effects of
  staff nurse perceptions of handoffs and
  transitions safety and overall patient safety on
  nurse-reported adverse patient events
  hemodialysis units?

12
Methods

• Sampling Frame
• ANNA members who identified themselves as staff
  nurses
• Mail survey Modified Dillman method
• Data analysis
• Multiple Regression
• Logistic Regression

13
Measures

• Series of questions to capture frequency of
  adverse events
• Hospital Survey on Patient Safety Culture
• Handoffs and Transitions Scale
• Patient Safety Grade
• Aiken staffing and process of care items
• Practice Environment Scale
• Individual Workload Perception Scale

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Sample (n 422)
Age Gender Female Male 48.6 93.4 6.6 Education Diploma Associates BSN MSN 17.8 37.3 41.9 2.7
Years in current role Years with employer Years in nursing 7.8 10.4 13.2
Race Unit Type
African American Asian/PI Hispanic White Other 6.7 7.4 1.9 82.6 1.2 Corporate-owned Hospital-owned 53.3 46.7
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Percent of respondents reporting at least monthly
to daily occurrences
Adverse Event of respondents
Dialysis hypotension Skipped dialysis treatments Shortened dialysis treatments Vascular access infiltration ER use due to volume overload Vascular access thrombosis Complaints from patient or family Unexpected bleeding from vascular access Vascular access infection Hospital admission due to pneumonia Patient received wrong medication or dose Patient fall in dialysis unit without injury Patient fall in dialysis unit with injury 92.3 82.6 82 67.5 59.3 58.6 58.1 55.4 51.9 35.5 14.7 4.8 4.1
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Handoffs and Transitions Safety
Scale Item of nurses with positive endorsements
Things fall between the cracks during patient shift change 28.4
Important patient care information is often lost during patient shift change 41.7
Patient shift changes are often problematic for patients in this unit 44.8
Problems often occur in the exchange of information during patient shift change 42.4
of sample with positive endorsement
Overall handoffs and transitions safety 39
17
Handoffs and Transitions Safety
Safety Grade of respondents
F (failing) 0.5
D (poor) 1.4
C (fair) 12.2
B (good) 48.4
A (excellent) 37.5
of sample with positive endorsement
Overall patient safety 86
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Relationship between safety variables and adverse
events plt.05 plt.01 plt.001
Adverse Event Handoffs/Transition Safety Grade
Hypotension -.15 -.15
Skipped Rx -.28 .23
Shortened Rx -.26 -.28
VA infiltration -.20 -.15
ER use -.16 -.22
VA thrombosis -.23 -.13
Complaints -.37 -.37
VA bleeding -.21 -.13
Infection -.12 -.14
Hospital admission NS -.10
Medication error -.24 -.17-
Falls without injury -.17 -.15
Falls with injury -.19 -.16
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Impact of negative nursing factors on odds of
adverse events plt.05 plt.01 plt.001
Adverse Event Low RN Staffing High Workload Unsupportive Work Environment Care Undone
Skipped Rx 5.25 3.05 4.43 5.17
Shortened Rx 3.71 2.45 3.51 3.11
VA infiltration NS NS 2.21 1.78
ER use 1.79 NS 2.21 1.78
VA thrombosis 2.02 2.07 2.10 2.32
Complaints 1.76 2.64 2.79 2.16
VA bleeding NS 2.31 1.99 1.78
VA infection 1.75 1.2 1.9 NS
Med error NS NS 2.23 2.44
Fall/no injury NS 4.93 6.25 NS
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Unadjusted effects of negative patient safety
ratings on odds of adverse events plt.05
plt.01 plt.001
Adverse Event Unsafe handoff and transitions Poor to failing safety grade
Skipped Rx 2.36 6.54
Shortened Rx 2.59 NS
VA infiltration 1.59 NS
ER use 1.77 2.10
VA thrombosis 2.16 NS
Complaints 3.16 4.33
VA bleeding 1.77 2.10
VA infection 1.87 2.52
Hospital admit NS 2.15
Med error 2.08 3.07
Fall/no injury NS 2.92
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Adjusted effects of negative safety ratings on
odds of adverse event occurrences
Adverse Event Unsafe Handoff and Transitions Poor to failing patient safety grade
Vascular access thrombosis 1.96
Patient complaints 2.61 3.28
Vascular access infection 2.17
Hospital admission 2.24
Medication error 2.42
22
Conclusions

• Adverse events, as reported by nurses, occur
  frequently in outpatient hemodialysis facilities
• Only 39 of nurses agree that patient handoffs
  and transitions during patient shift change are
  safe
• 86 of nurses grade overall patient safety in
  hemodialysis units as good to excellent

23
Conclusions

• Negative ratings of handoffs and transitions was
  independently associated with higher odds of
  vascular access thrombosis and patient complaints
• Poor to failing safety grade was independently
  associated with higher odds of patient and family
  complaints, medication errors, vascular access
  infection, and hospital admissions

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Conclusion

• Phenomenon of patient safety culture is complex,
  abstract, and inferred by perceptions of
  individuals
• Patient safety culture may be a meaningful
  indicator of patient safety and risk for adverse
  events in outpatient dialysis settings
• Ongoing, standardized assessments of patient
  safety culture dimensions can help to identify
  problem areas that may lead to adverse events