A Systematic Literature Review of Safety Culture in Hemodialysis Settings

Background

Patient safety is the establishment of top-notch medical services, which is also considered a crucial part of the quality of medical centers. It is progressively recognized that strengthening the safety culture in medical centers is vital to uphold the quality of care. Safety culture can be defined as the individual’s product, group beliefs, behavior patterns, values and attitudes, competencies, and perceptions that show or determine the commitment level of an organization to patient safety and quality care.¹ Moreover, the same attributes are used to determine how the organization is committed to enhancing the quality of patient safety in renal care.

Building safety culture is fundamental for making a high quality associations in medical care.^2–4 Dialysis facilities are not exceptions and need to ensure safety and quality of care and foster a culture that enhances patient safety. There are a range of risk sources and contributory factors that patients might experience in hemodialysis settings, one of which is the infection risks due to the regular need to access bloodstreams using catheters and needles. Patients might be infected in the various parts of the body such as the lungs, bones, vascular access points, bloodstreams and even the skin. These infections obtained in dialysis settings or during dialysis can extend the condition, or even lead to death which in turn disrupts the patient’s normal living and also incurs high costs of dialysis.⁵ Reasons why patients may acquire infections include patients staying close together, faulty equipment, blood-borne viruses, expedited turnover amid dialysis, and being constantly admitted to the center. Implementation of prevention guidelines, protocols and strategies that reinforce safety culture excellence are essential to mitigate such risks as well as adequate staff training. These settings are required to attain specific standards including adequate staff, proper and well-maintained equipment and regular maintenance of facilities.

In previous safety culture assessment of hemodialysis settings, there has been minimal incorporation of qualitative research, with none having a systematic review that gathers all reported methods to comprehensively identify the safety culture drivers in such settings. Therefore, our research aims to address the following question: “What are the safety culture assessment tools used in hemodialysis settings?” In order to address this, we identify and review the main methods, tools and strategies used to improve the safety culture at hemodialysis settings. Although safety culture can be measured and compared across institutions,^6,7 the methods hospitals should use to improve safety culture have yet to be defined. To synthesize published literature and draw actionable inferences, we conducted a systematic literature review to compile all the various strategies and improvements that can be implemented to strengthen the safety culture in hemodialysis settings.

Method

This systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.⁸ The PRISMA statement includes a checklist for systemic evaluations (see Supplement file). Firstly, we included the studies that focus on strategies for improving safety culture in hemodialysis settings. Secondly, our articles were selected from two databases: MEDLINE (via PubMed) and Scopus. Thirdly, we decided that our search strategies should be used in both databases including two Boolean operators; “OR” when keywords were similar (like dialysis or hemodialysis) and included “AND” for adding more keywords to the search (like safety culture, patient safety). Finally, Table 1 shows the search strategy used in MEDLINE (via PubMed), whereas the search strategy of Scopus is shown in Table 2.

Table 1 MEDLINE (via PubMed) Search Strategy

Table 2 Scopus Search Strategy

Eligibility Criteria

The inclusion criteria considered while screening and selecting the papers were based on the following: (i) studies related to improving the safety culture in hemodialysis units, (ii) studies that were published in the English language, (iii) studies published between January 2010 and December 2020, (iv) studies published in journals, (v) studies that were conducted in hemodialysis settings.

Selection Process

The search using the two databases (PubMed and Scopus) identified 505 titles. After eliminating duplicate titles, we were left with 227 articles for screening, which was conducted by four researchers (S.A., A.A., T.A., and A.A.). Of these, 177 were discarded after the title and abstract screening. After that, 29 papers were excluded because of not meeting the criteria’s considered for this study, such as abstracts, short conference proceedings, and non-English papers. Four papers were also removed after reading the full text and not getting useful information about safety in hemodialysis settings, leaving 17 papers for extraction and analysis. Figure 1 shows a flowchart of the article selection in detail.

Figure 1 Study selection flowchart. Notes: PRISMA figure adapted from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009; 6(7):e1000097. Creative Commons.9

Results

Study Characteristics

The 17 studies originated from 6 different countries, Figure 2 shows the worldwide distribution of the contributing countries. Moreover, Table 3 shows a range of quantitative and qualitative data that were extracted from the 17 included studies. Quantitative data included sample size and follow-up duration (months), whereas qualitative data included country, objective, outcome measures, results, improvement strategies and study limitations.

Table 3 Characteristics of the Selected Studies

Figure 2 Number of publications by country.

Discussion

We conducted a systematic review to identify ways of improving the safety culture at hemodialysis settings. We identified 17 eligible studies that had quantitative and qualitative data and extracted best practices to achieve an almost “zero error” hemodialysis environment.

Three papers discussed how to improve and ease the process of the dialysis nurse’s job in general^13–15 and concluded that developing an effective analysis tool that is affected by “predisposing factors, medication errors, disabling factors and reinforcing factors” to improve the nursing care in hemodialysis settings is an important first step. Two studies were concerned about the nurse’s role in the management of continuous hemodialysis in the intensive care unit (ICU) setting.^16,17 Process improvements identified for ICU nurses working for continuous hemodialysis patients includes establishing a strong background and knowledge about the technologies they are working with, and strong training so they can anticipate any unexpected patient case. Along with this, a collaborative model should be adopted in the sector, including a systematic strategy to support and assist new nurses.

Second, designing a Hemo Pause Checklist for daily use by nurses can reduce adverse events and strengthening the safety culture in the dialysis unit by. However, more established and demonstrated patient safety estimation devices might be required. These improvements should be implemented to get the process done in the most efficient way and to prevent the errors that may occur because of a failure to follow protocols. Another three papers^18–20 discussed strategies for preventing infections in hemodialysis units to improve the patient safety culture in hemodialysis units. For instance, infections may be prevented by using methods such as system thinking, recognizing the complexity of the system and interrelatedness among various system components.

Three studies identified other points of risk for adverse patient events in hemodialysis settings, such as threats to safety during a transition of care in the dialysis settings.^21–23 These three papers advised implementing the root cause analysis method to determine system and process issues that lead to adverse events. One study used Failure Mode and Effect Analysis (FMEA) to find the severity, frequency and detection of each event and assigned real errors, then implemented the prevention measure that could improve patient safety culture in hemodialysis settings.¹⁹ The role of effective communication in improving the safety culture in hemodialysis settings was emphasized in multiple studies,^19,21,24,25 including the responsibility of leadership to encourage open communication and mutual trust with and between employees.^8,20,24 Open communication will lead to a positive safety climate and therefore will promote a free-blame environment.^26,27 Another study emphasized the importance of patient and staff communication as it considered the vital role of patients’ feedback during treatment in improving safety.²⁵ A final article suggested studying effective performance indicators and implementing them to solve any future challenges hemodialysis settings may face.²⁸

Limitations

The search to two databases (PubMed and Scopus) because they were considered suitable for gathering all qualifying papers by the proposed topic and objectives, but this restriction may have missed some relevant articles, and some identified articles were not accessible to the research team. The search was narrowed to those published in journals and the English language. An important limitation was that most of the papers did not test their proposed improvements in the healthcare settings, so we were not able to discern the outcome of each strategy. Further, limited evidence is available regarding the role of different stakeholders, such as physicians and nurses, in the safety culture assessment and improvement. Ultimately, the inferences that can be drawn from available evidence are limited by the paucity of published research related to the safety culture in hemodialysis settings.

Conclusion

Improving hemodialysis patient safety is a vital priority. The category of papers included in this review showed that risks to patient safety may relate to transitions of care, failure to use checklists to ensure compliance with protocols, and communication gaps between the hospital staff, and between the staff and patients. Therefore, this review showed that efforts should be made to overcome these gaps. Moreover, it also highlighted how to prevent infections from happening in the beginning, by implementing these improvements; the safety culture in the hemodialysis settings will turn into an almost “zero error” environment and a safe place for the patients to receive their treatments. Finally, based on our knowledge, this is the first systematic review that clustered diverse improvement strategies from selected studies in the literature and reviewed them to improve safety culture in the hemodialysis settings. This study may be a starting point for upcoming studies concerned with improving the safety culture in hemodialysis settings.

Future studies can benefit from testing the improvement strategies that were identified to prove their effectiveness, as most of the strategies proposed in this systematic literature review were not tested for impact on outcomes. Further, a comparison analysis between the proposed strategies can be conducted to provide the decision-makers with the best strategy to enhance safety culture.