Patient Safety Culture and Nurse- Reported Adverse Patient Events in Outpatient Hemodialysis Facilities Charlotte Thomas-Hawkins, PhD, RN Linda Flynn, RN, PhD, FAAN

College of Nursing 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

College of Nursing Work Environment Support for Nursing Practice Patient Outcomes Process of Care Care Left Undone Nursing Structures RN-to-pt ratios Workload Nursing Organization and Outcomes Model Aiken et al., 2002

College of Nursing 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 NS2.72**0.45*** Shortened TX3.79***2.03**0.27*** Skipped TX2.27**1.92**0.34*** ComplaintsNS3.00**0.53*** **p <.01, *** p <.000 Thomas-Hawkins, Flynn, Clarke, 2008 (Adjusted effects)

College of Nursing 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 organization’s health and safety management. Sorra & Dyer, 2010

College of Nursing Dimensions of patient safety culture Sorra & 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

College of Nursing 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

College of Nursing 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

College of Nursing Handoffs and Transitions in Dialysis Units

College of Nursing Work Environment Patient Safety Culture Support for Nursing Practice Patient Outcomes Process of Care Handoffs and Transitions Safety Care left undone Nursing Structures RN-to-pt ratios Workload Nursing Organization and Outcomes Model Aiken et al., 2002

College of Nursing 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?

College of Nursing Methods Sampling Frame –ANNA members who identified themselves as staff nurses Mail survey – Modified Dillman method Data analysis –Multiple Regression –Logistic Regression

College of Nursing 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

College of Nursing Sample (n = 422) Age Gender Female Male 48.6 % Education Diploma Associates BSN MSN % Years in current role Years with employer Years in nursing Race%Unit Type% African American Asian/PI Hispanic White Other Corporate-owned Hospital-owned

College of Nursing 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

College of Nursing 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

College of Nursing 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 safety86

College of Nursing Relationship between safety variables and adverse events *p<.05; **p<.01; p<.001 Adverse EventHandoffs/TransitionSafety Grade Hypotension-.15*** Skipped Rx-.28***.23*** Shortened Rx-.26***-.28** VA infiltration-.20***-.15*** ER use-.16***-.22*** VA thrombosis-.23***-.13* Complaints-.37*** VA bleeding-.21*-.13** Infection-.12*-.14*** Hospital admissionNS-.10* Medication error-.24***-.17-*** Falls without injury-.17***-.15*** Falls with injury-.19***-.16***

College of Nursing Impact of negative nursing factors on odds of adverse events *p<.05; **p<.01; p<.001 Adverse Event Low RN Staffing High Workload Unsupportive Work Environment Care Undone Skipped Rx5.25***3.05***4.43***5.17*** Shortened Rx3.71***2.45**3.51**3.11** VA infiltrationNS 2.21**1.78* ER use1.79*NS2.21**1.78* VA thrombosis2.02**2.07**2.10**2.32** Complaints1.76*2.64***2.79***2.16** VA bleedingNS2.31**1.99**1.78* VA infection1.75*1.2**1.9*NS Med errorNS 2.23*2.44** Fall/no injuryNS4.93*6.25*NS

College of Nursing Unadjusted effects of negative patient safety ratings on odds of adverse events *p<.05; **p<.01; p<.001 Adverse EventUnsafe handoff and transitions Poor to failing safety grade Skipped Rx2.36***6.54** Shortened Rx2.59***NS VA infiltration1.59*NS ER use1.77**2.10* VA thrombosis2.16***NS Complaints3.16***4.33*** VA bleeding1.77**2.10* VA infection1.87**2.52** Hospital admitNS2.15** Med error2.08*3.07*** Fall/no injuryNS2.92*

College of Nursing 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 complaints2.61***3.28** Vascular access infection 2.17* Hospital admission2.24* Medication error2.42*

College of Nursing 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

College of Nursing 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

College of Nursing 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