Report Highlights Top Safety Concerns
By Christine Kern, contributing writer
Alarms, health IT, and patient violence top the list of safety issues for patients.
An ECRI Institute report highlights root causes for serious patient safety events, outlining the top 10 patient safety concerns for healthcare organizations. This report, Top 10 Patient Safety Concerns for Healthcare Organizations, is published “to give healthcare organizations a gauge to check their track record in patient safety.”
Since 2009, ECRI has collected more than 500,000 reports of adverse safety events, and combines them with knowledge gained from reviewing more recent safety incidents to develop the list. Four of the top patient safety concerns on this list also are mentioned on ECRI’s 2015 list of top health technology hazards.
“This is more than just a list; it’s a reminder that despite the attention given to patient safety over the last 15 years or so, we can do better,” explains William Marella, MBA, executive director of operations and analytics, ECRI Institute Patient Safety Organization (PSO). “Healthcare providers, regardless of what setting they practice in, can start with our top 10 list of patient safety concerns and use it to guide their own discussions about patient safety and improvement initiatives.”
Topping the list this year were alarm hazards, including inadequate alarm configuration policies and practices. “In our experience, alarm-related adverse events – whether they result from missed alarms or from unrecognized alarm conditions – often can be tracked to alarm systems that were not configured appropriately,” notes the ECRI.
The second concern is Data Integrity, including incorrect or missing data in EHRs and other health IT systems, which could result life-threatening events, followed by managing patient violence. This concern was reflected by the fact clinical staff in patient units commonly lack training in behavioral health which may lead them to miss behavioral cues that signal imminent violence.
Rounding out the top 10 concerns were incorrect connection of IV lines resulting in misadministration of drugs and solutions; care coordination events related to medication reconciliation; failure to conduct independent medication double checks; opioid-related events including over-sedation and respiratory depression, gastrointestinal adverse events, hyperalgesia, pruritus, and immunologic or hormonal dysfunction; inadequate reprocessing of endoscopes and surgical instruments; inadequate patient handoffs related to patient transport; and medication errors related to pounds and kilograms.