Top 10 Patient Safety Concerns

The ECRI Institute released its annual Top 10 list of patient safety concerns, in which health I.T. has a leading role. The list is based on the institute’s database of patient safety events voluntarily submitted by provider facilities, as well as custom research requests and root-cause analyses submitted to ECRI.

Data Integrity Failures with HIT Systems Data Integrity Failures with HIT Systems

The integrity of data in health IT systems can be compromised from any of the following: data entry errors, missing data or delayed data delivery, inappropriate use of default values, copying and pasting older information into a new report, use of both paper and electronic systems for patient care, and patient/data association errors (i.e., patient data from a medical device is mistakenly associated with another patient’s record).

Poor Care Coordination with Patient’s Next Level of Care Poor Care Coordination with Patient’s Next Level of Care

Events reported to ECRI reveal gaps in communication about patients’ care—between hospital and providers, among providers, and between long-term care settings and hospitals or other providers. The report also notes that with increasing pressure to shorten hospital stays, many patients are discharged to post-acute care settings to continue their rehabilitation, such as post-stroke care or rehabilitation following joint replacement surgery.

Test Results Reporting Errors Test Results Reporting Errors

Delays or failures to report test results to ordering providers were among the top types of errors in the laboratory testing process found in an ECRI “deep dive” analysis of laboratory testing. Test results reporting errors represented 10% of all 2,420 events reviewed for the analysis.

Breakdowns in test results reporting, particularly in physician practices, typically have one of three causes or a combination of them: (1) technology limitations, such as an inadequate interface between an EHR system and a laboratory system that provides the results electronically; (2) provider-to-provider communication gaps, such as those that occur when no backup plan is in place to designate a provider to review test results for another provider who is unavailable or on vacation; and (3) staffing and training failures, such as requiring a staff member to periodically check an EHR system for test results but not informing the person of what to expect in terms of the volume of test results typically reported to the practice.

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Drug Shortages Drug Shortages

The potential patient care implications of drug shortages came to the attention of the ECRI Institute when a hospital contacted the PSO about a severe shortage of emergency drugs. The hospital was unable to replenish its supply of injectable unit-dose medications stored on its crash carts for patient resuscitation and wanted to know whether its remaining supply of expired drugs could be used instead.

Drug shortages will remain an ongoing concern, the report predicts. To control costs, manufacturers keep their drug inventories low, focusing on making and supplying their products as orders are submitted. Hospitals also keep a just-in-time approach to inventory so that unused products are not left on their shelves.

Failure to Adequately Manage Behavioral Health Patients in Acute Care Settings Failure to Adequately Manage Behavioral Health Patients in Acute Care Settings

Several events reported to ECRI Institute highlight the challenges for staff in acute care settings in managing the behavioral health needs of patients, particularly those who exhibit psychiatric illness or emotional agitation in addition to their acute clinical needs. Many of these reports describe incidents of patient violence, some of which cause harm to the patient, staff, or others. Healthcare providers who are not trained in behavioral health may not recognize that’s what these behavioral signals mean, and they may not have sufficient training on how to respond, according to the report.

A report author notes that “Healthcare providers, while possibly anxious about the patient’s behavior, usually continue with the patient’s medical care or assessment. These are very dedicated people. Their objective is to provide care, and when the patient is resisting, they’re being challenged to accomplish their mission.”

Mislabeled Specimens Mislabeled Specimens

Specimen mislabeling is the leading type of event in the laboratory testing process identified in an ECRI Institute “deep dive” analysis on laboratory testing. Mislabeled specimens (e.g., a specimen with a label from a different patient, two contradictory labels, or a label that does not correspond with the order) represented 31% of all 2,420 events reviewed for the analysis.

Retained Devices and Unretrieved Fragments Retained Devices and Unretrieved Fragments

Although attention has been given to the risk of unintentionally leaving a surgical item in a patient after surgery, childbirth, or an interventional diagnostic procedure, reports to ECRI Institute and other event reporting programs, as well as investigations by ECRI Institute’s Accident and Forensic Investigation Group, indicate that these events continue to occur, even though they can largely be prevented.

Retained items can involve an entire device, such as a surgical sponge or towel, unknowingly left behind, or a portion of a device that breaks away and remains inside the patient. Risks to the patient include prolonged or additional surgery when a retained item is discovered and removal is deemed appropriate or future complications if the retained item leads to infection or causes damage to surrounding tissue.

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Patient Falls While Toileting Patient Falls While Toileting

"Although hospitals have implemented regularly scheduled rounding of patients in their rooms with an emphasis on falls prevention, the typical rounding schedules don’t always work for people in terms of their need for toileting,” says geriatrician Karen Schoelles, M.D., director of ECRI Institute’s Evidence-based Practice Center.

During rounding, nurses may ask if the patient needs to use the bathroom. Schoelles suggests modifying the question to be more specific. “Rephrase the question by asking, ‘Do you want to go now or the next time I come in?’” says Schoelles, who was an ECRI Institute coauthor of a falls prevention toolkit available from the Agency for Healthcare Research and Quality (AHRQ).

Inadequate Monitoring for Respiratory Depression in Patients Taking Opioids Inadequate Monitoring for Respiratory Depression in Patients Taking Opioids

For more than a decade, Joint Commission accreditation standards have underscored patients’ rights to have their pain assessed and managed. Healthcare providers have responded with an intensified focus on pain management, using pain medications such as opioids. Increased use of opioids also raises the possibility of adverse events. Opioids are considered a high-alert medication. These drugs have a heightened risk of causing significant patient harm if used in error. The most serious adverse effect of opioids is respiratory depression, which is often preceded by sedation.

Several event reports submitted to ECRI Institute suggest that patients receiving opioids are not being adequately assessed and monitored for respiratory depression.

Inadequate Reprocessing of Endoscopes and Surgical Instruments Inadequate Reprocessing of Endoscopes and Surgical Instruments

Because instrument reprocessing is “very process-oriented, healthcare organizations need to have good procedures in place to be sure all steps for cleaning and disinfecting are happening,” notes a report author. “If any step in the process is missing, problems can happen” with the transmission of infectious agents and the spread of diseases, such as hepatitis C, HIV, and tuberculosis, from contaminated instruments and devices.

One area in particular is adequately rinsing the instrument and allowing it to dry. ECRI Institute has analyzed reports of reprocessing failures with flexible endoscopes, as well as reports of inadequate reprocessing of other instruments and devices, such as arthroscopy shoulder cannulas and surgical instrument trays.

Access the Full Report Access the Full Report

The ECRI Institute provides more information on patient safety concerns as well as suggestions on how to address them in the full report, which can be accessed here. Registration is required.

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The ECRI Institute released its annual Top 10 list of patient safety concerns, in which health I.T. has a leading role. The list is based on the institute’s database of patient safety events voluntarily submitted by provider facilities, as well as custom research requests and root-cause analyses submitted to ECRI.

 

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