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Report: Health IT and Patient Identification Errors Are Top Patient Safety Concerns

April 15, 2016
by Heather Landi
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Within healthcare delivery organizations, when health IT configurations and organization workflow do not support each other, communication suffers, which is why the ECRI Institute cited this issue as its top patient safety concern in its annual executive brief.

This week, the ECRI Institute, a non-profit organization focused on improving the safety, quality and cost-effectiveness of patient care, released its third annual Top 10 Patient Safety Concerns for Healthcare Organizations executive brief. According to an announcement about this year’s list from the ECRI Institute, the list is meant to guide healthcare organizations on where to direct their patient safety initiatives.

In selecting this year's list, ECRI Institute drew on its databases of reported safety events as well as the literature, and sought out expert judgment. As a result, the list underscores that “these are real things that are happening,” according to Catherine Pusey, R.N., associate director, ECRI Institute Patient Safety Organization. “They're happening at a serious level, our members are asking questions around these topics, and we're seeing them in many different manifestations,” she stated.

Topping the list this year is health IT configurations and organization workflow that do not support each other. According to ECRI Institute, when a health IT system is implemented, organizations need to tailor the configuration to the workflow and vice versa. But often, “after the implementation, people continue to do things the same way and really don't adjust the health IT system or their workflow,” Robert Giannini, patient safety analyst and consultant, ECRI Institute, said in a statement.

Patient identification errors ranked second on the list, as, during reviews of reported patient safety organization (PSO) events, ECRI Institute analysts discovered that patient identification errors "were not only frequent, but serious.”

Inadequate management of behavioral health issues in the non-behavioral-health setting ranked third on this year's list. “This concern is evident when hospital patients may behave aggressively due to psychiatric disorders, reactions to their treatment, or other reasons when not in the behavioral health unit. These circumstances can lead to injury or even death of patients or staff,” the ECRI Institute release stated. “All staff need to be trained to work with patients with behavioral health needs and participate in frequent drills.”

The reminder of the list was as follows:

Inadequate cleaning and disinfection of flexible endoscopes

Inadequate test-result reporting and follow-up

Inadequate monitoring for respiratory depression in patients prescribed opioids

Medication errors related to pounds and kilograms

Unintentionally retained objects despite correct count

Inadequate antimicrobial stewardship

Failure to embrace a culture of safety

According to ECRI Institute, although not all patient safety concerns on the list apply to all healthcare organizations, many are relevant to a range of settings across the continuum of care.

“Patients move fluidly between settings throughout their lives, which makes us interdependent in meeting each individual's healthcare needs,” Victor Lane Rose, operations manager for ECRI Institute’s aging services risk management program, said in a statement.


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