Top challenges in improving patient safety in 2017
Several information technology practices are among the top 10 patient safety concerns that provider organizations are dealing with in 2017. The list of the most significant concerns was released this week by ECRI Institute, a patient safety organization.

ECRI annually publishes the list to identify potential safety risks within healthcare delivery systems and improve overall safety in patient care. ECRI, which compiled the report, based its conclusions on event data from its Patient Safety Organization, concerns raised by healthcare providers and on expert judgment.
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1. Information management in EHRs
Healthcare providers have troves of information to manage, and the advent of electronic health records has brought this challenge to the forefront. But the goal is still for people to have the information that they need to make the best clinical decisions.

Organizations must approach health IT safety holistically, ECRI says. One key step is integrating health information management professionals, IT professionals and clinical engineers into patient safety, quality and risk management programs. Other strategies include ensuring that users understand the system’s capabilities and potential problems; encouraging users to report concerns and investigating these concerns; engaging patients in information management; and harnessing the power of EHRs to enhance patient safety.
2. Unrecognized patient deterioration
During the past few decades, concerted efforts have enabled speedier recognition of and response to stroke and heart attack. Certain other conditions—including sepsis, some maternal conditions and postsurgical complications—need the same type of prompt recognition and attention for patients to have good outcomes. Organizations must cultivate staff competencies in rapidly identifying conditions.

Practice (simulations) and use of tools (early-warning criteria) may aid speedy recognition. Clinicians can proactively assess patients’ risk, plan for appropriate care and monitoring, educate at-risk patients and supplement with technology monitoring. Organizations can develop condition-specific protocols for an organized and speedy response and analyze work systems and processes to identify and address barriers.
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3. Implementation and use of clinical decision support
Clinical decision support encompasses tools that we use to ensure that the right information is presented at the right time within the workflow. But if use is suboptimal, opportunities may be missed. Patient harm, as well as disruption of clinical workflows and provider frustration, could result. Healthcare organizations must design CDS systems judiciously; resources are available from HealthIT.gov, ECRI Institute and others.

A multidisciplinary team should have oversight. End users must be trained in the proper use of CDS, as well as their roles and responsibilities, and have access to support structures. On an ongoing basis, organizations should monitor the effectiveness and appropriateness of CDS alerts, evaluate the impact on workflow and review staff response to alerts. The tool should be redesigned as necessary.
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4. Test result reporting and follow-up
Testing is a complex process. When inadequately managed, this complexity can contribute to fragmentation. Sometimes clinicians become very task oriented—labs ordered, blood drawn and sent, imaging ordered, X-ray completed—and they lose sight of the big picture. Critical thinking and teamwork get lost when they’re focusing on just their assigned tasks.

Organizations should analyze their test result reporting systems and monitor their effectiveness in triggering appropriate follow-up. Policies and procedures should clearly designate accountability for acting on test results. To help close the loop, organizations can facilitate two-way conversations among healthcare professionals involved in treatment and those involved in diagnostic testing. Patient engagement and health literacy strategies can be used to teach patients what to do and why it is important.
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5. Antimicrobial stewardship
Selecting drugs for treating many bacterial infections is becoming increasingly limited and expensive. Inappropriate prescribing is a key factor. If prescribing habits do not change, more people will die from infections for which there is no treatment.

Healthcare organizations may decide to hold prescribers accountable for adherence to treatment guidelines. A physician advocate can lead the effort and talk to other physicians as a peer. Organizations also can educate patients, family members and the general public about antimicrobial stewardship and the reasons for it. The Centers for Disease Control and Prevention has outlined core elements for antibiotic stewardship for hospitals, nursing homes and outpatient settings.
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6. Patient identification
Although the majority of the 7,613 events analyzed for ECRI Institute’s patient identification report were caught before they caused patient harm, about 9 percent resulted in patient injury, including two deaths. The report bought national attention to an issue that most healthcare providers recognize as a significant problem.

Leaders can start by fully supporting patient identification initiatives by prioritizing the issue, engaging clinical and nonclinical staff, and asking staff to identify barriers to safe identification practices. Redundant processes for patient identification can increase the likelihood of preventing patient mix-ups. Elements such as electronic displays and patient identification bands may be standardized. When used as intended, bar-code systems and other technologies can also support safe patient identification.
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7. Opioid administration and monitoring in acute care
In conducting analysis for an upcoming study on opioid safety, ECRI noted problems with opioid administration and patient monitoring. These are the same issues with administration seen with other medications. However, unlike some of these other medications, opioids can have catastrophic consequences.

Organization may evaluate and address work system and process factors that may contribute to opioid administration errors, such as organizational culture and workload.

Best practices can be implemented for patient identification, medication purchasing, labeling, dispensing, use of bar-code medication systems and independent double-checks. Staff must carefully assess patients before and after administration, using an opioid-induced sedation scale. For certain patients, capnography or minute ventilation monitoring can supplement nurse monitoring.
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8. Behavioral health issues in non-behavioral health settings
Healthcare organizations do not always recognize when a patient has behavioral health needs and the needs go unmet. This can cause hostile or aggressive behavior which can frighten or frustrate staff, especially if they lack training or support. Comprehensively assessing all patients can help providers proactively determine patients’ behavioral health needs.

All staff should be trained to recognize early signs or cues of behavioral health needs, use non-offensive techniques and de-escalate a situation, and participate in frequent drills. Behavioral emergency response teams, which staff can call when a patient’s behavior becomes agitated or threatening, can be implemented to support early assessment and response.
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9. Management of new oral anticoagulants
Since 2010, four new oral anticoagulant medications have been approved. In an ECRI analysis of events involving these agents, almost 34 percent of events for which a harm score was provided resulted in patient harm, ranging from temporary injuries to death. We need more awareness of the proper use of the agents; it’s not “one size fits all and you’re done.”

Standardized order sets should specific doses for the different medications, based on indication. Organizations can use clinical decision support systems to alert practitioners to duplication of therapy and track responses to alerts. A multidisciplinary team plans for reversal of anticoagulant therapy, and reversal agents should be more readily accessible. Collection and analysis of events involving new oral anticoagulants can help organizations identify further prevention strategies.
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10. Inadequate systems or processes to improve safety and quality
Numerous studies show a link between error prevention and a culture of safety. Root-cause analyses are vital, as is being proactive rather than waiting until a patient is harmed. Strategies can be used to examine processes, identify what can go wrong and make the process less vulnerable to error before mistakes can be made. Strong prevention strategies such as standardization and automation should be explored.

Leaders must support a culture that emphasizes learning rather than blaming. Individual accountability must be balanced with organizational responsibility to design and improve systems to ensure safe care. All organizations should have an actionable quality and patient safety plan with high-level approval.