Interactive Session
May 10, 2002
McLean, Virginia

Dr. Derrick Latos introduced the topic, followed by Dr. Barbara Fivush who presented an overview of safety science, national activities focused on patient safety, and activities specific to the renal community.  Dr. Jack Moore facilitated an interactive session to gather the audience's viewpoint. 

The blame-free environment and organizational culture necessary to impact on safety issues was emphasized.  Top patient safety issues, identified by Network 5 providers, are listed below and illustrated in the attached graphs.  The audience identified possible causes, which are also listed below, by discipline.  The last segment includes possible solutions that were contributed by the audience.

Top Patient Safety Issues Identified by Network 5 Providers

	1.       Access related events
	2.       Excess blood loss
	3.       Medication errors
	4.       Violent patients
	5.       Exposure to blood/body fluids

Patients' Perspective

• Unresponsive administrative system
• Problems are hidden
• Inadequate staff
• Poorly paid staff
• Overworked staff
• Inadequate support

Social Workers' Perspective

• Staff bringing human needs/problems to work
• Unprofessional staff is tolerated
• Lack of interdisciplinary communication
• Expedient behavior
• Patients that behave inappropriately have no resources available to them
• Working environment is stressful
• Staff overworked and underpaid

Physicians' Perspective

• Safety is not the mission of central priority
• Poor/inadequate supervision of existing procedures
• Staff not following protocol
• Lack of opportunity for professional training

Administrators' Perspective

• Inadequate staff
• Inability to secure adequate staff
• Nursing/technicians/nephrologist shortages
• Litigations
• Bad reimbursement
• Inadequate training/follow-up/supervision
• Not manufacturing safe "mechanisms"
• Regulatory agencies
• Creating a culture where people feel comfortable coming forward is difficult
• Not much leadership "buy-in"
• Highly complex patients consume time

Nurses' Perspective

• Unfocused staff
• Nurses afraid to question
• Staff not following what they know is right
• Inadequate training of new staff
• Problems with the types of patients coming to dialysis today
• Staff shortages
• Hurried environment-staff and patients want in and out of center quickly
• Bottom line
• Poor physical environment
• MD's aren't listening to nurses
• Not "nephrology" related impairments are not treated
• Often no primary doctor
• Physician unresponsiveness
• Insurance/payment systems
• Insufficient time for continuing education
• Unfriendly technology
• Environment not conducive to creative and analytical thinking