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ECRI Institute Releases Top 10 List of Patient Safety Issues for 2018

March 16, 2018
by Heather Landi
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When health IT systems are poorly designed, or when the organization’s culture fails to embrace health IT safety, patients can suffer, according to the ECRI institute, which named incorporating health IT into patient safety programs as one of its top patient safety concerns.

The ECRI Institute, a non-profit organization focused on improving the safety, quality and cost-effectiveness of patient care, released its fifth annual Top 10 Patient Safety Concerns for Healthcare Organizations executive brief. According to the ECRI Institute, the annual list is meant to help organizations identify looming patient safety challenges and offers suggestions and resources for addressing them.

In selecting this year’s list, the ECRI Institute relied on its Patient Safety Organization (PSO) event data, concerns raised by healthcare provider organizations, and on expert judgment to select the topics for the 2018 list. Since 2009, when ECRI Institute PSO began collecting patient safety events, the PSO and partner PSOs have received more than 2 million event reports and reviewed hundreds of root cause analyses.

Within the top 10 list of patient safety issues, health IT safety programs was ranked fifth. A health information technology (IT) safety program can play a pivotal role in improving the safety and quality of healthcare, but its success depends on the ability of users to recognize, react to, and report health-IT-related events for analysis and action. If staff fail to recognize health IT issues when they emerge, then they may not know how to intervene, according to the ECRI Institute executive brief. “It is not only how we use [health IT] in daily workflow, but also how we use it effectively by optimizing the benefits and reducing the risks,” Robert C. Giannini, patient safety analyst and consultant, ECRI Institute, said in the executive brief.

The ECRI Institute recommends that facilities focus on integrating health IT safety into the existing safety program, collaborating with stakeholders, and embedding health IT safety into the organization’s culture.

Diagnostic errors ranked as the top patient safety issue for healthcare organizations in the 2018 report, followed by opioid safety across the continuum of care, then internal care coordination. The ECRI Institute ranked workarounds as the fourth top patient safety issue.

The remainder of the list was as follows:

Management of behavioral health needs in acute care settings

All-hazards emergency preparedness

Device cleaning

Disinfection and sterilization,

Patient engagement and health literacy

Leadership engagement in patient safety

Regarding diagnostic errors, according to both studies and claims analyses, diagnostic errors are common, and they can have serious consequences. Diagnostic errors are also challenging to measure and learn from because they often go undetected until after the patient leaves the hospital or emergency department (ED). “Healthcare organizations should capture data on diagnostic errors and near misses. Sources may include the event-reporting system, malpractice and payment claims, patient complaints, patient surveys, autopsies, and record reviews. The organization can then make changes to address gaps. Discussing the topic in multiple forums, such as grand rounds and debriefings, can support ongoing analysis and learning for clinicians,” the ECRI Institute report states.

Over-prescription, abuse and misuse of opioids is an issue impacting hospitals and healthcare providers across the country, and it’s a patient safety concern because of the seriousness of the side effects of opioid medications. The ECRI Institute recommends a number of strategies for healthcare organizations, including comprehensively assessing patients, using nonpharmacologic modalities and nonopioid pain medications, and accounting for patients’ individual needs, opioid tolerance, and comorbidities. Sedation scales and, for high-risk patients, continuous monitoring can help detect respiratory depression.

The ECRI Institute listed internal care coordination as the third top patient safety issue as poorly coordinated care can put patients at risk for safety events such as medication errors, lack of necessary follow-up care and diagnostic delays. To address these risks, the report recommends healthcare organizations improve communication with other providers with the use of handoff tools, checklists and safety huddles to help ensure providers communicate effectively at every stage of the patient’s care.

Given the major hurricanes, wildfires, mass shootings and ransomware attacks that occurred in 2017, it is not surprise that all-hazards emergency preparedness made the top 10 list of patient safety issues for healthcare organizations.

“I don’t know that there’s any way to prevent any future natural disasters, or even most intentional disasters,” Patricia Neumann, R.N., patient safety analyst/ consultant, ECRI Institute, said in the report. “Obviously preparing is a whole lot better than having to recover.”

The report also identified patient engagement and health literacy as a top patient safety issue that healthcare organizations should address. “We don’t do a great job of engaging patients and making sure they understand their health and healthcare, and we underestimate how often those failures lead to serious harm,” Josi Wergin, risk management analyst, ECRI Institute, said in the report.

Experts recommend taking “universal precautions” for health literacy—making all materials and discussions easy to understand. “Ways to engage patients include bedside rounds, daily goal sheets, and patient coaching. Eliciting patients’ goals and connecting them with recommended actions is a key step. If patients still do not adhere to the plan of care, investigate why, Wergin suggests. Organizations can also partner with government and community groups to tackle social determinants of health,” the report states.

 

 

 

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