The Emergency Care Research Institute, (ECRI) Patient Safety Organization (PSO) has issued its 2015 “top 10 list” of safety concerns for multiple healthcare settings, such as hospitals, ambulatory care centers, doctor’s offices and nursing homes.[i] This year’s list is as follows:
- Alarm hazards: inadequate alarm configuration policies and practices; the investigations found that hospitals have had a lack of, or inconsistent practices to determine how alarms are set by care area or patient type. In past years, attention had been focused more on “alarm fatigue,” meaning missed alarms due to excessive activations.
- Data Integrity: incorrect or missing data in EHRs and other health IT systems; healthcare organizations need better testing of the electronic health record (EHR) systems, as well as checks and balances, to identify and address missing or incorrect data.
- Managing patient violence; aggressive or agitated behavior signals a high-risk, high acuity situation that warrants immediate clinical attention.
- Mix-up of IV lines leading to misadministration of drugs and solutions; these errors result in wrong-drug, wrong-rate, wrong dose, or wrong-site infusions which sometimes have serious consequences.
- Care coordination events related to medication reconciliation; at every care transition such as admissions, transfers and discharges, the patient’s medications need to be reconciled to ensure the patient is on the correct medications for the next phase of care.
- Failure to conduct independent double checks independently; in blood banking, having two practitioners perform an independent double check of the blood group before transfusion has been a long-time requirement.
- Opioid-related events; the increasing use and dispensing of opioids has led to overdose, over-sedation, respiratory depression, gastrointestinal adverse events, pruritus and immunologic or hormonal dysfunction. The most common events reported to the ECRI database for this category involved hydromorphone, oxycodone, opioids used in PCA, and fentanyl patches.
- Inadequate reprocessing of endoscopes and surgical instruments: a multistep cleaning and disinfection process must be followed or organisms may remain on the devices.
- Inadequate patient handoffs related to patient transport: safety concerns reflected in the analyzed data include patients being transported to the wrong department, the wrong patient being transported and patients left unmonitored at the receiving site.
- Medication errors related to pounds and kilograms: the miscalculation of weight-based doses and weight being incorrectly entered in the EHR are reported in the data.
New to the 2015 top 10 list were numbers 1, 4, 6, 9 and 10. Issues which had appeared on previous listings, but are not found on this year’s top 10, indicating improvement in those areas, include mislabeled laboratory specimens and patient falls during toileting.
The ECRI largely bases its top 10 list on reports submitted by hospitals to the ECRI Institute PSO. It is suggested that by proactively using ECRI’s top 10 list, a medical provider can improve the quality of care and also comply with the provisions of the Joint Commission’s recently released patient systems chapter for its 2015 accreditation manual.
Healthcare providers are encouraged to use the top 10 list of patient safety concerns as a trigger for discussing and setting their own patient safety priorities.
ECRI Institute PSO also compiles a top 10 list for health technology hazards, with 4 overlapping topics as to patient safety concerns.[ii] Those 4 overlapping areas are:
- Alarm hazards: inadequate alarm configuration policies and practices.
- Data Integrity: incorrect or missing data in EHRs and other health IT systems.
- Mix-up of IV lines leading to misadministration of drugs.
- Inadequate reprocessing of endoscopes and surgical instruments.
A main reason for why technology appears on both of the ECRI top 10 lists, has to do with, first, the growing complexity of technology and, second, a marked increased reliance on technology in delivering healthcare.
Also making the ECRI top 10 list for health technology hazards, is insufficient cybersecurity protections for medical devices and systems. While it is said there is little evidence of direct harm to patients from cybersecurity breaches, it is predicted that cybersecurity will be a patient safety concern in the near future.