ECRI Institute has released its most recent list of the top ten patient safety concerns facing healthcare institutions today. Many of these affect a broad spectrum of healthcare settings, including acute care hospitals, outpatient services, nursing homes and hospice care.
Similar to the Medication Management Council established by Omnicell, which developed its Top 10 Safety Best Practices for medications, ECRI recommends that healthcare institutions use the list as a starting point in their discussions about patient safety, and as a guide for establishing safety standards. By reviewing these top concerns, facilities can better understand the risks that exist at their particular organization, and can work to reduce relevant hazards.
- Alarm Hazards – Alarm fatigue—caused when healthcare providers are overwhelmed by or desensitized to the multiple alarms that activate—has been the main focus of alarm hazards, but institutions should consider other factors as well. For example, alarms that fail to activate when a patient is in distress is a safety issue.
To improve safety, take into consideration the range of influences that can lead to alarm hazards, and develop an effective program for alarm safety.
- Data Integrity – A growing patient safety concern involves data integrity errors resulting from incorrect or missing information in electronic health records (EHRs) and other health IT systems. While technology offers numerous benefits to healthcare institutions, it can also create new safety risks if not designed, implemented and used conscientiously. With EHRs in particular, incorrect data is more readily available, more easily shared and more difficult to eliminate.
Lack of integrated data is also a concern. Consider the following example involving two separate health IT systems—EHR and dietary management. The patient’s peanut allergy was listed in the EHR but was not relayed to the dietary department—it was only discovered after the patient received a food tray that was not free of peanut products.
Other instances of data integrity failure include the appearance of one patient’s data in another patient’s record, default values being used by mistake, and outdated information being copied and pasted into a new report.
To combat these errors, try to identify data failures as they happen, and report all incidents, even if they do not cause direct harm.
- Managing Patient Violence – Each day, healthcare institutions deal with threatening behaviors by patients that put staff, visitors and other patients at risk. Patient violence is not just an issue in the emergency department, but extends to all care settings, including oncology and maternity units.
However, staff in acute care units typically lack the training needed to handle patients who become violent, or they fail to acknowledge the incidents. Many healthcare providers feel threatening patient behavior is a workplace hazard that must simply be tolerated, which leads to underreporting of this issue.
In addition to requiring reporting and training staff in de-escalation strategies, develop a safety plan that considers all levels of risk, from a minor act of aggressive behavior to an active shooter on the campus—and include both physical security and response tactics in your plan.
- Misadministration of IV Drugs and Solutions – IV line mix-ups can severely impact patient safety, resulting in wrong drug, wrong rate, wrong dose or wrong site infusions. Patients who have multiple IV infusions and/or leads and cables for physiologic monitors are at even greater risk.
To prevent infusion line confusion, trace all lines back to their origin before making connections, recheck lines upon the patient’s arrival in a new setting, label each infusion line and standardize the position of different lines so they are more easily identified.
- Care Coordination Events Related to Medication Reconciliation – Insufficient medication reconciliation endangers patient safety. Medication reconciliation at admission is challenging to conduct unless the patient has kept accurate records of previous medications. At each care transition, the patient’s medications should be reconciled to ensure the patient is on the correct meds for the next stage of care.
To ensure accuracy, double check the patient’s medication list against another source, such as the patient’s pharmacy, but keep in mind that when a patient is admitted, providers may opt to discontinue some or all medications until the patient’s needs can be properly identified. During discharge, check the medication list for errors in order to accurately reconcile a patient’s medications.
- Failure to Conduct Independent Double Checks Independently – In blood banking, independent double checks before transfusion are standard procedure. But for high alert medications, the same requirements are not always in place. When double checks are used, the failure to conduct them in a truly independent way is often a major issue.
To alleviate this risk, healthcare workers must be aware of the importance of independent double checks. Auditing and observing the actual process is one way to ensure checks are conducted properly.
- Opioid Related Events – Prescription and use of opioids has increased in recent years, raising numerous patient safety concerns, including overdose, gastrointestinal adverse reactions, hyperalgesia, pruritus, and immunologic or hormone dysfunction. The increased potency of today’s opioids is often not taken into consideration when prescribing, leading to overdose. In addition, healthcare providers sometimes fail to distinguish patients who are opioid-tolerant from those who are opioid-naïve.
Prescribers should be educated about opioid safety and opioid-related events, and understand when and if a patient requires an opioid. Staff should be trained to monitor opioid-induced sedation as well.
- Inadequate Reprocessing of Endoscopes and Surgical Instruments – Healthcare facilities reprocess thousands of reusable surgical instruments each day for subsequent use. But the potential harm to patients from transmission of infectious agents remaining on reusable devices is serious. Certain devices are difficult to clean, and the process involves multiple steps that must be executed correctly from start to finish. Each device comes with unique sterilization instructions, as do disinfectant solutions and cleaning agents, further complicating the process.
Evaluate any changes made to reprocessing procedures, such as using a different disinfectant that may require a longer soak time, to determine if other steps in the process need to be adjusted.
- Inadequate Patient Handoffs Related to Patient Transport – Transporting a patient within the facility to another clinical setting or between units can lead to safety risks for the patient. Patients could be transported to the wrong department, the wrong patient could be transported or patients may be left unmonitored at the receiving site. Transportation risks vary with each patient. For example, critically ill patients are exposed to periods of instability during transport.
Transport policies and procedures should be based on a number of factors, including equipment availability; assigning responsibility for troubleshooting equipment during transport; determining training, experience and competency required of transport personnel; and implementing tools and checklists to support proper handoff communication at the receiving site.
- Medication Dosage Errors Related to Pounds and Kilograms – Mix-ups between pounds and kilograms can happen in any healthcare setting that has a scale. This safety concern affects both children and adults, and overdoses involving high-alert medications can be particularly harmful. For example, if a patient’s weight is entered in the EHR incorrectly (e.g. pounds for kilograms), the medication would be dosed for more than double the patient’s true weight.
The most effective strategy to reduce this risk is to get rid of scales that measure in pounds or to adjust electronic scales so they only display in kilograms.
To learn more about these patient safety risks, download a PDF of the ECRI 2015 Top 10 Patient Safety Concerns for Healthcare Organizations report here.
See our previous blog post about the Medication Management Council’s Top 10 Safety Best Practices here.