ECRI Institute released its second annual Top 10 Patient Safety Concerns for Healthcare Organizations list today to help organizations determine where to direct their efforts. Half of the concerns are new for 2015 and the other half are recurring or variations of concerns from 2014.
ECRI assembled the list by reviewing its database that includes patient safety events, root-cause analyses and custom research requests reported by health care organizations and its partner patient safety organizations throughout the year.
Since 2007, alarm hazards have made it to the top of ECRI’s Top 10 Health Technology Hazards lists, and this year it’s number one on this list. Most of the literature published on this topic focuses on alarm fatigue but ECRI believes there is more to the issue than that.
Alarm-related adverse events resulting from missed alarms or unrecognized alarm conditions are also an issue and usually stem from alarm systems that aren’t configured properly. As part of the Joint Commission’s National Patient Safety Goal, ECRI suggests that organizations examine their alarm configuration policies and procedures.
Issues related to health IT have also been a recurring issue on ECRI’s top 10 technology hazard lists. Incorrect or missing information is entered into EHRs and other health IT systems, resulting in data integrity issues.
Those issues range from one patient’s data being entered into another patient’s record and outdated information being copied and pasted into a new report. To fix this, ECRI explained that organizations have to identify these issues as they happen to prevent similar issues from occurring in the future.
Patient violence is another problem, and the clinical staff in acute care units usually doesn’t possess the training in behavioral health to be aware of signs that indicate imminent violence. ECRI believes that training staff members in de-escalation strategies can curb coercion, empower them to engage patients with threatening behavior and uphold safe conditions at the same time.
Mixing up IV lines is a dire issue because it can lead to patients getting too much of a certain kind of medication. To prevent that, ECRI recommends tracing lines back to their origin before connecting the IVs, creating a policy to position different lines on different sides of the patient, labeling each line with the name of the medication and not forcing connections.
Medication reconciliation is another issue that organizations need to focus on. When a patient is discharged, the provider should not give them any new medications that they weren’t taking while in the hospital.
