In ECRI’s third annual list of patient safety concerns for health care facilities, analysts examined the institute’s database, along with reviewing reported Patient Safety Organization (PSO) events, and found the top 10 concerns for patient safety.

“We considered both data on events and concerns, and the judgment of experts in various disciplines from within and outside ECRI,” Josephine Wergin, ELS, certified professional in aging services risk management at ECRI, told HCB News.

The top of the list is health IT configurations and organizational workflow not properly supporting each other.
When a health IT system is put in place, staff members need to customize the configuration to the workflow, and the workflow to the configuration, according to the announcement. When health IT configuration and workflow clash, communication suffers.

However, after implementation, staff members continue to work the same way without adjusting the IT system or workflow, said Robert C. Giannini, NHA, certified health care technology specialist and implementation manager, clinician consultant and patient safety analyst, ECRI Institute, in a statement.

Number two on the list is patient identification errors. “As seen in the report, one of the most serious events occurred when the wrong chart was retrieved to verify a patient’s code status,” Stephanie Uses, PharmD, MJ, JD, patient safety analyst at ECRI, told HCB News, “The person was a full code but died; he was not resuscitated because the patient in the chart retrieved was listed as a do-not-resuscitate code status.”

Number three is inadequate management of behavior health issues in non-behavioral-health settings. According to the announcement, when hospital patients behave aggressively due to psychiatric disorders, reactions to their treatment, or other reasons, staff members may not know the proper way to help the patient.

Here is the complete list of concerns.

• Health IT configurations and organizational workflow that do not support each other


• Patient identification errors


• Inadequate management of behavioral health issues in non-behavioral-health settings


• 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

“Number 10, failure to embrace a culture of safety, rounds out our list because … culture safety allows organizations to identify patient safety concerns and align the motivation and resources needed to address those concerns,” said Wergin.

“Patients move fluidly between settings throughout their lives, which makes us interdependent in meeting each individual’s health care needs,” said Victor Lane Rose, NHA, MBA, certified professional in aging services risk management and operations manager at ECRI, in a statement.

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