Table 3.

Characteristics of the Selected Studies

Author, Year, Country	[Sample Size]/ [Follow-Up (Months)]/ [Outcome Measure/Methodology]	Objective	Results	Improvement Strategies	Limitations
B. R. P. de Andrade, F. de M. Barros, H. F. Â. de Lúcio, J. F. Campos, and R. C. da Silva 2019, Brazil16	[23 nurses]/ [3 months]/ [Interviewed using a script]	Report nurse’s role in the management of the ICU in continuous hemodialysis.	ICU nurses in continuous hemodialysis are given the role to perform preparations and follow-up activities, by interacting with technologies based on interaction with technology and the use of specialized knowledge.	ICU nurses in continuous HD must be familiar with the technologies they are using. To locate the dialysis units close to the ICU, so that nurses can collaborate.	Not many national experienced nurses in the ICU of continuous Hemodialysis.
C. Thomas-Hawkins and L. Flynn 2015, USA21	[422 registered nurses]/ [3 months]/ [Survey]	Study the relation between patient safety culture and nurse-reported adverse events in the outpatient hemodialysis units.	39% of nurses had recognized that patient transitions in the dialysis units were safe, and 86% had graded patient safety as either good or excellent.	Reducing the number of patients coming and leaving the therapy at the same time could decrease interruptions and have a safer patient transition. Minimize errors and adverse events by the dialysis unit’s elasticity or slack staffing models. Have individual peer review and root cause analyses to find out the issues in the system that causes adverse events.	The staff nurse sample may have different characteristics from nurses working in hemodialysis units.
A. Thomas et al 2016, Canada13	[14 nurses and 22 patients]/ [3 months]/ [Hemodialysis safety checklist (Hemo Pause)]	Determine the value of using the Hemo Pause checklist during hemodialysis sessions.	93% of hemodialysis nurses agreed that the Hemo Pause checklist was easy to use. 93% want the checklist to be used during their hemodialysis sessions. 73% of the hemodialysis patients found that the checklist made them feel safer. 79% of nurses and 73% of patients agreed it should be expanded to other patients.	Dialysis unit staff must be trained in using the checklist. The need for an understanding and validated patient safety measurement tool.	Testing the checklist only for 3 months, thus, it is possible that the checklist completion rate may not be helpful. The findings were limited to a small number of self-selected nurses and patients. No evidence to prove that the checklist used improves patient safety culture, the patient experience or patient outcomes. Less staff training of the checklist during the summer vacation months.
Kliger 2015, USA22	[Not mentioned]/ [Not mentioned]/ [Not mentioned]	To identify the occurrence of errors, and how to reduce or eliminate them, and chances to improve the process faster.	[Not mentioned]	Illuminate care processes by root cause analysis of adverse events. Improve communication by using tools such as safety huddles, read-backs, and checklists. Improve safety and develop procedural skills by simulation training in vascular access.	[Not mentioned]
R. Garrick, A. Kliger, and B. Stefanchi 2012, USA23	[1143]/ [3 months]/[Surveys]	Application of safety principles to dialysis facilities.	Dialysis facilities share significant safety concerns, and patients express greater concern about unit safety procedures than workers would expect.	Anticipate the problems that might happen ahead of time and try to avoid them. Root cause analysis should be used to determine the problem. Employees and patients should be able to voice their opinions in a blame-free setting. ‘plan-do-check-act’ cycle should be used.	The East Coast received more responses than the other countries, and physicians had the lowest response rate. Since there was no opportunity to participate, competent respondents could represent those who are most concerned about safety.
T. Millson, D. Hackbarth, and H. L. Bernard 2019, USA10	[100 dialysis patient/ month]/ [12 months]/ [Surveys among 6 facility destinations]	Reduce the risk of infection in hemodialysis patients inside an outpatient dialysis facility. Enhance organizational commitment to evidence-based strategies for reducing BSI in the dialysis environment.	Reviews showed improvements from 27%-82% of methods performed accurately. Circulatory system disease rates diminished from 2.33–1.07 occasions per 100 patients.	Unit-based Safety Program is a successful model in improving the safety culture. Upgraded patient wellbeing society is associated with improved patient results.	Just one health care organization’s outpatient dialysis service was included in the initiative. Because of time and cost constraints, the intervention was only initiated at one of six outpatient dialysis centers.
L. P. Wong 2019, USA18	[Not mentioned]/ [Not mentioned] / [Surveys based on focus group]	Eliminate dialysis infections and target zero infections.	[Not mentioned]	The clinical chiefs and the board should outline ideal consideration as the consequence of associated colleague activities. There should be cautious consideration paid to establish an environment of mental wellbeing, whereby colleagues can pose inquiry and express opinions.	[Not mentioned]
B. R. P. de Andrade, F. de M. Barros, H. F. Ângela de Lúcio, J. F. Campos, and R. C. da Silva 2019, Brazil17	[23 nurses]/ [4 months]/ [Observations and semi structured interviews]	Analyze intensive care nurses’ clinical experience and its effect on their work experiences in the continuous hemodialysis environment and patient safety in the ICU.	Experienced nurses have a tough time dealing with problems that limit their presentation in comparison to the demands of patients. The level of expertise influences the well-being of nurses’ practices during continuous hemodialysis administration.	The collaboration model that will be implemented in the sector should establish systematic methods that will enable dialysis nurses to more closely accompany new nurses. Provide training to junior nurses such that they can gain more experience.	Limited experienced nurses working in the ICU in the continuous Hemodialysis centers.
Kristina K. Davis, Kathleen G. Harris, Vrinda, Mahishi, Edward G. Bartholomew, Kevin Kenward 2016, USA11	[599 Administrative leaders, Physician, Dietician, Nurse and others]/ [Not mentioned]/ [Modified HSOPSC Survey]	To evaluate the safety culture of hemodialysis centers via a modified HSOPSC.	Overall hemodialysis facilities scored high on items regarding safety culture. According to this study, areas with the most potential for improvement in hemodialysis facilities included treating each other with respect, mistakes leading to positive changes, and staff members freely speaking.	One important improvement strategy was related to the staff size, whereas size increases the composite patient safety score went down. This may indicate that facilities with fewer staff may tend to have more involvement in implementing improvement projects that focus on how to address patient safety.	The response rates are unknown; those who did respond may be systematically different than those who did not. The assessment tool used only 10 items to measure safety culture; thus, it is not a comprehensive safety culture assessment.
Leslie P. Wong 2018, USA19	[Not mentioned]/ [Not mentioned] / [Systems Thinking]	To provide a novel approach to prevent infections in dialysis facilities.	[Not mentioned]	The Institute of Medicine (IOM) has proposed System Thinking as a way of embracing continuous learning and improvement to aid in managing the healthcare system complexity.	[Not mentioned]
Attilio Di Benedetto, Francesco Pelliccia, Manuela Moretti, Wanda d’Orsi, Fernando Starace, Laura Scatizzi, Maria Teresa Parisotto, Daniele Marcelli 2011, Italy24	[346, physicians, registered nurses and health care assistants]/ [Not mentioned]/ [Safety Climate Survey & Universal Hygiene Precautions questionnaires]	[Not mentioned]	The mean overall score for Safety Climate was 81.9%. The mean overall score for Universal Hygiene Precautions was 90.8.	To develop a stronger and harmonized safety climate, it is essential to close the gap between safety climate scores of leadership and frontline staff. Fostering communication between the groups might help to close this existing gap. Promoting open communication and mutual trust between managers and employees. This will lead to a positive safety climate and therefore for a good safety culture. This might also avoid the reluctance of employees in reporting safety concerns. Implementation of training programs and continuous education is of fundamental importance for the whole team. In particular, as highlighted from the lower scores obtained in the HCA group, there is a need to integrate all who are caring for the patients, in the vision of safety.	Both questionnaires had a predefined range of answer choices in the form of rank-based responses on a Likert-type response scale. The questionnaires did not contain any open-ended questions. Since respondents were asked to complete all questionnaires anonymously, there was no way to draw a causal distinction between the two.
Alexandre R. Marra, Oscar Fernando Pavão dos Santos, Miguel Cendoroglo Neto, Michael B. Edmond 2013, USA20	[Not mentioned]/ [Not mentioned] / [Positive deviance (PD)]	This study discusses an approach for infection prevention that promotes a safe culture in healthcare settings. In addition, it allows for more resilient cultural changes that aim at improving the frontline compliance with the infection measures.	[Not mentioned]	The proposed PD approach is especially appropriate in circumstances where organizations should monitor outcomes using valid performance metrics and there is significant natural variance in performance.	[Not mentioned]
Letícia Lima Aguiar 2019–2020, Brazil14	[5 papers]/ [1 month]/ [Systematic literature review to conduct the survey questions]	Investigate the nursing care factors that are associated with the safety culture of chronic renal patients on hemodialysis.	Factors called ‘causal factors’ that were presented above 50% of the papers were selected. As a result, “effect of falls reduction” was described as a risk factor; “vascular access infections”, “medication errors”, and “hypotension” as crippling factors; and “adequate staffing” and “providing security protocols, practices, and guidelines” as safety culture strengthening factors.	Use the factors found predisposing factors, medication errors, disabling factors and reinforcing factors to develop an effective analysis tool that can be used during the dialysis treatment.	The study was limited to the hemodialysis nurse’s safety care in Brazil and Latin America.
Samuel A Silver, Alison Thomas, Andrea Rathe, Pamela Robinson, Ron Wald, Ziv Harel, and Chaim M Bell 2015, Canada15	[20 nurses]/ [Not mentioned]/ [Delphi process based on RAND method to evaluate and review the checklist]	Foster a Hemodialysis Safety Checklist (Hemo Pause) for everyday use by nurses and patients.	From the 31 parameters founded, 19 was chosen to get the agreement from the team and Nephrology personnel which got higher than 75The result assigning the errors based on their importance using FMEA, patient body weight errors represent the highest; dysfunction/rupture of the catheter; and needle extravasation represent the lowest.% agreement.	Create a Hemo Pause Checklist to prevent adverse occurrences and promote the dialysis unit’s safety culture.	The study of the literature was not comprehensive. It was a one-site analysis. The group needed patients and family portrayal.
María Dolores Arenas Jiménez, Gabriel Ferre, Fernando Álvarez-Ude 2017, Spain12	[97 hemodialysis patient from 35 dialysis centers]/ [Not mentioned]/ [Failure mode and effect analysis FMEA technique]	Identify drug errors that may occur in hemodialysis systems, as well as underlying actual or possible errors, and evaluate their magnitude, frequency, and identification, using the Failure Mode and Effects Analysis (FMEA) method to determine their objectives.	As a result of prioritizing errors using FMEA, errors attributable to patient body weight rank highest, catheter dysfunction/rupture rank second, and needle extravasation rank third.	Study the most important error that may occur in hemodialysis units and using FMEA allows assigning real errors, then implementing the prevention measure could improve safety.	The observation period was short. Failure detection was based on the records. The study was conducted in a single center (actions that should be considered as failures should be reviewed by more professionals and patients).
Hu-Chen Liu and Kenji Itoh 2013, Japan28	[24 papers]/ [Not mentioned]/ [Questionnaire survey to dialysis experts, systematic literature review to select indicators]	Evaluate the performance of the dialysis department and comprehensively support them not only from quality and safety but also from the patients and employee’s satisfaction.	Most of the indicators were assigned negatively (meaningless to management dialysis). Patients, on the other hand, listed several important metrics, such as indicators relating to patient care and patient safety, which are crucial for health department management.	Study the effective performance indicators and implement them to solve future challenges.	Few experts contributed to this study. Responses were biased because all participants were from the hospital staff.
Lucia New, Donna Goodridge, Joanne Kappel, Gary Groot and Roy Dobson 2019, Canada25	[30 patients]/ [5 months]/ [Face to face interview with patients (recorded interview)]	Study CKD patients’ experience in the safety of dialysis centers and reporting the incident that occurs during their treatment period.	Patients complained about treating them in a room with other patients that may have infection disease which put them at risk besides having visitors from their roommate, lack of cleaning in the rooms. According to the patient’s response, there is a lack of communication between the team providers and them. Patients are not aware of reporting safety concerns by phone; they were complaining of lack of communication with providers while they did not recognize this way and used it.	Consideration of patient feedback to improve the safety during the treatment.	The result represents data collected from tertiary hospitals and may not apply to other hospitals. Some records are missing for some patients who are at CKD and also for those who do not speak English.