Dialysis Patient Safety

Patients Help Pave the Road in Error Prevention

As healthcare consumers, we are informed, "CMS [Centers for Medicare & Medicaid Services] is committed to its beneficiaries and aims to ensure that they receive the right care at the right time. Giving the right care, to the right person, at the right time is the basis of patient safety and is a concern of everyone in the healthcare field.¹" Patient safety should be of concern to patients and their loved ones as well. The dialysis industry informs us their facilities provide quality, safe care, and the Renal Physicians Association supports quality of care for kidney patients and patient safety.² As recipients of care, with the potential to be unsafe, is it not reasonable to include patients in this process? Healthcare providers should ensure that all facilities are delivering safe care, that patients are educated to their fullest ability, and that patients are active participants in facility patient-safety programs. This patient-centered role will provide input resulting in error reduction. Action is needed now.

The Human Element

Humans make mistakes, but being able to prevent them can be rewarding to caring professionals, and appreciated by patients. "Always remember that dialysis carries with it the inherent possibility of being dangerous to a patient, and should be regarded as both a life-saving and a life-threatening procedure. Respect the process for what it is and be aware at all time of the possibilities for crisis.³"

Mindful attention is needed by those providing care and should be stressed during staff education programs. Those administering treatments must understand the gravity of each treatment. This life-sustaining treatment, a most complicated process, deserves deliberate yet purposeful and cautious attention. This attention can mean the difference between a comfortable treatment and one that results in negative outcomes, including death.

With any luck, we will soon see a national Kidney Disease Safety Coalition. Let us not get caught up in reinventing the wheel. That which is identified below—reasons for mistakes, safety issues and conclusions—indicates the need for providers to strengthen their existing patient-safety programs, or to immediately implement a program. Patients being educated, with active participation, is a a necessity, whereby patients can address their safety concerns—what they see, or what they can’t see, e.g., water treatment.

In all due respect, to providers, would you, or a loved one, want to be at the receiving end of an avoidable error? Therefore, all the more reason to educate patients for their own protection.

Patient education, provided by physicians and staff, will result in minimizing error occurrences. The following are basic examples.

1. Patients, educated about reportable symptoms, can alert staff when they feel dizzy or unsteady, thus preventing falls.

2. Patients, educated about their medications—purpose, dosage, time (every treatment, once a month, end of treatment, etc.), can prevent wrong medications, wrong dosage or omissions from occurring. (Staff, upon administration, must provide the name, dosage and purpose of medication.)

3. Patients, educated about their access, will know cannulation areas, will be aware when a problem with their access develops, i.e., lack of thrill, infection, etc. Patients can provide direction to new staff who are inexperienced in cannulation.

4. Patients, educated on the dialysis procedure, dialysate and labs (connection between their potassium level and dialysate), will be able to identify if the wrong potassium bath is being used. (Staff should provide dialysis prescription updates to patients.)

5. Educated patients will be aware that if staff press on the needle during removal. The result can be prolonged bleeding; therefore, patients can tell staff not to press hard which can tear the vessel, or patients when started on new anticoagulant therapy, such as as Plavix or Coumadin, etc., will be educated to inform staff to identify possible reason for prolonged bleeding.

6. Of great concern is the lack of handwashing before touching the patient’s access. Considering that infection continues to be the second leading cause of death, this is most disturbing. Patients can prevent an acquired infection by being educated on appropriate practices that staff will be implementing and, if incorrect practices are observed, patients can remind staff to implement those practices that are safe.

It takes a team effort of patients and staff, working together, to reduce error occurrences.

The Patient-Provider Relationship

The patient-provider relationship is defined differently by patients and includes, but is not limited to, patient’s care expectations, prior experiences, including but not limited to healthcare, individual needs, beliefs and values, desire to be educated or not, and feelings about requiring dialysis. The collective experiences brought by patients, staff and physicians influence this relationship-building process. The patient must learn to trust each and every staff member and physician with whom they come in contact. Each has their own personality that the patient must adjust to, along with each staff member having their own style of delivery of care.

The dialysis culture is different than other healthcare settings, and it can support or rapidly destroy this relationship. Staff dynamics within the unit are a major component that can interrupt the educational process. It only takes one staff member to sabotage this process. The contagious behavior when one staff member (or physician) voices negative comments about a patient or labels a patient can disrupt the evolving relationship that often needs cultivating and nurturing. In many units, staffers bond and tend to support each others’ subjective opinions—this is reality. Management must not support, in any way, these negative statements, nor make their own negative comments, as it contributes to the disruption of the relationship process. This is a challenge for managers, and objectivity must be the foundation when problems appear in the growing relationship.

The Patient-Safety Program

Patients should be educated, encouraged to identify safety concerns and actively involved in their unit’s patient-safety program, or other similar QI committees/projects. Providers who understand the true meaning of patient-centered care will actively engage and encourage participation.

Patients appreciate caring professionals who, through a challenging, yet rewarding process, are able to identify and correct problems in order to have an end result of a decrease in error occurrences.

Error Identification. Staff should be encouraged to report error occurrences, no matter how minimal. Staff should report other staff observed having error occurrences. The unspoken code of not reporting an observed error, of a coworker, is unacceptable and perpetuates a system where mistakes will continue to happen.

Error Investigation. A thorough investigation is considered necessary to determine all contributing factors of cause. There must be staff honesty. If the incorrect procedure was implemented by staff, it is imperative to identify if the staff was knowledgeable and aware of the correct procedure. If so, it is essential to understand why the correct procedure was not implemented. Not following procedures is unacceptable and more reason for patients to be educated for their own protection. Is it considered an intentional act when a staff implements an incorrect procedure, resulting in potential or actual harm, if, in fact, the staff had knowledge of the correct procedure implementation and did not conduct same?

Error Correction. Re-education provided to staff to ensure understanding of why incident occurred and how to prevent reoccurrence of incident.

Error Trending. Accurate trending of errors can prevent continued same or similar error occurrences.

Healthcare transparency can prevent errors and should extend to the dialysis setting. Facility staff should be given the opportunity to read their facility survey, which will increase appreciation for negative consequences of incorrect practices and possibly decrease error occurrences. Surveys should be available for patients/families to read. If facilities believe they are providing quality safe care, there is no reason not to provide a copy of the survey. Patients, aware of deficient practices, can become educated, along with staff, in order to ensure they are receiving safe care. Management can review survey findings with interested patients and provide educational information. Until patients can be assured that procedures will be followed, as well as staff being adequately educated, there must be more of a collaborative effort—patient-provider—to ensure a safe environment. With transparency, patients have a right to know if their facility is providing quality, safe care in order to protect themselves.

The Challenge of Educating Patients

I have been told by some that patients do not want to be educated; they want to have their treatment and leave. I am sure this is true for some patients. The challenge lies within the process of evaluation and assessment to determine which patients want to be educated, which do not, which cannot—due to cognitive and/or medical problems—and which, with encouragement, will want to be educated. Patients have differing educational needs. It is important to understand why a patient does not want education, and, if such is determined after assessment, then this must be respected. It is also important to understand why a patient wants to be thoroughly educated. The assessment process must be ongoing to determine changing educational needs. All patients should be afforded the opportunity to be educated to the fullest extent possible.

Providing patient education is ineffective and a waste of time unless the patient is able to understand and make use of the information. It is critical that this process has a built-in component that identifies if the patient has processed the information in order to use same. It is not enough to assume the patient has understood provided information.

When providing educational materials, obstacles need to be understood by staff in order for the process to be effective. These obstacles can include problems in staff-patient relationships, cognitive difficulties, medical problems, hearing and visual impairments and language barriers. In addition, we are seeing a rise in the elderly population, who are often not afforded the same involvement in their care, or education, as are young and middle-aged patients.

Judging from what I have learned through my communications, the ideal educational program includes the following.

1. A patient educator in each facility.

2. Patients should be given a binder upon admission that has detailed information on all aspects of dialysis. This can be used by the patient throughout their entire dialysis experience at their own pace. Patients should be able to use this as their bible any time they need reference material or education (not all patients have computers whereby they can obtain information, nor can some patients drive to a library). Modules for patients to work on can be beneficial, and depending on the patient, staff can play a major role in working with the patient and their educational binder.

3. Educational groups, e.g., dietary, lab, resources, dialysis procedures, medication, and a support group.

4. Individual one-on-one education.

5. Handouts must be thoroughly explained to patients and not just handed to them. Follow-up is needed to ensure understanding. Graphs/diagrams should be explained to patients.

6. Patients should be encouraged to actively participate in care plan meetings with all disciplines present to discuss concerns related to treatment.

7. Educational videos, DVDs, audio tapes, Braille material.

8. Educational posters on walls that are simplified for all patients to understand, e.g., pictures, colored diagrams, drawings.

9. Staff should explain each and every task performed and ask patient if there are questions.

10. Patients should be asked about their safety concerns and how they feel about reporting them.

11. Education on how staff will prevent transmission of infectious agents, e.g., those effective infection control practices that will be implemented to prevent spread of infectious agents.

12. Education on the dialysis treatment/procedure, explaining each step in the process, including what each identified area on the panel means, e.g., UFR, BFR, etc.

In conclusion, patient education and active participation must not be undervalued. Don’t let patients be the missing piece in the puzzle that will complete the process towards an error-free environment. Provide care as you would want care delivered to yourself or a loved one.

Roberta Mikles, RN, BA, is a healthcare patient advocate based in Rancho Bernardo, Calif. She can be reached at RMiklesRN@aol.com

References:

1. http://cms.hhs.gov/ESRDQualityImproveInit/downloads/patientsafety.pdf

2. http://www.hdcn.com/symp/07rpa/content/07rpa_pro_hand.pdf

3. "Avoiding the Malpractice Blues" by Mary Rau-Foster, RN BS ARM JD, Contemporary Dialysis & Nephrology magazine, October 1999). http://www.fosterseminars.com/armpblues.htm

4. www.esrdncc.org/index/cms-filesystem-action?file=/AM_2007_HealthSafetySurveyProject.ppt

An Effective Relationship

The foundation of an effective patient-provider relationship includes, but is not limited to, the following points. The opposite of these are obstacles that interfere with the developing patient-provider relationship, halt the educational process, and thereby continuing to support the occurrence of errors.

1] Staff being accepting and encouraging when patients identify potential or actual errors—understanding the patient has a right to verbalize those practices that might place them at risk.

2] Staff demonstrating open, accepting attitudes when patients ask questions related to their care. This is part of providing ongoing education.

3] Staff encouraging patients to be an active part of the team, e.g., participation in care planning meetings, active involvement in their treatments, involvement in patient-safety programs and quality improvement committees.

4] Unhindered ability for patients to bring forth concerns or complaints without fear of staff resentment or retaliation (underlying behaviors as facial expressions or body language, or verbal comments, can deter patients from bringing forth concerns or asking educational questions, thereby contributing to continued error occurrences).

5] Staff being fully cognizant and understanding of what a patient is experiencing at the beginning of their dialysis journey, as well as throughout their entire dialysis journey.

6] Staff being non-judgmental, objective and not placing labels on patients.

7] Staff being upfront and honest with patients, no matter how minimal or extensive, when an error occurs, thereby building the trusting relationship.

8] Staff providing accurate answers to patients.

9] Staff demonstrating acceptance when patients bring suggestions that might improve their lives.

10] Staff demonstrating a sincere caring, concerned and respectful manner

11] Staff addressing patient needs in a timely manner.

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