Organizations across the continuum of care are striving to become high-reliability organizations, and part of being highly reliable means staying vigilant and identifying problems proactively. ECRI Institute’s annual top 10 list helps organizations identify looming patient safety challenges and offers resources for addressing them. Below is a brief excerpt.
#1 Diagnostic Stewardship and Test Result Management Using EHRs
When diagnoses and test results are not properly communicated or followed up, the potential exists to cause serious patient harm or death. Providers have begun relying on the electronic health record (EHR) to help with clinical decision support, to track test results, and to flag issues. However, the EHR is only part of the solution. Three key components – the diagnosis, the treatment plan, and the follow-up plan – must be clearly communicated in the EHR. To help “close the loop,” providers must not only fully utilize an EHR designed to meet their practices’ unique needs, but also recognize the importance of clear communication, both among caregivers and between caregivers and patients.
#2 Antimicrobial Stewardship in Physician Practices and Aging Services
The health care system needs to combat antibiotic resistance before the situation gets worse. As antibiotic resistance increases, treatment options can be limited. Perhaps the most significant challenge facing antibiotic stewardship is managing patient expectations in all care settings. Unnecessary antibiotic administration puts patients at unnecessary risk of adverse drug reaction, and the broadest concern is that overprescribing leads to antimicrobial resistance.
#3 Burnout and Its Impact on Patient Safety
Burnout affects physicians (including trainees), nurses, allied health care providers and organizational leaders alike. Studies show that burnout has a consistent negative relationship with safety and quality. If burnout is to be addressed effectively, organizations must listen to providers’ concerns about workload, performance criteria, and suboptimal resource allocation and fix these problems at a system level. Moving to a safety culture that rewards and recognizes a job well done is necessary.
#4 Patient Safety Concerns Involving Mobile Health
Risks of mobile health technology include lack of regulation of new technologies, barriers to ensuring that providers are accurately receiving the data a device collects, and the possibility that a patient is not using the technology correctly or is not using it at all. Many devices are released without U.S. Food and Drug Administration testing. Health care organizations must ensure the safety and validity of any device they recommend to a patient and be certain the device will work when the patient leaves the health care facility.
#5 Reducing Discomfort with Behavioral Health
The fear of working with individuals with behavioral health needs can lead providers and staff to behave in ways that fail to meet patients’ needs or even escalate situations, with consequences for patients and staff. In many health care settings, behavioral and physical health are siloed. All providers and staff need communication skills. Options to improve these skills include certified training, training led by internal experts or consultants, community behavioral health first-aid workshops or a combination of modalities.
#6 Detecting Changes in a Patient’s Condition
Failure to detect changes in a patient’s condition is an ongoing patient safety concern across the continuum of care. Problems can arise within a care unit and during transitions of care within a facility and from one facility to another. Technology can alert caregivers to a patient’s changing condition, but it must be used appropriately. Staff must be trained in how to operate the equipment and understand the organization’s policies and their responsibilities for responding to alarms.
#7 Developing and Maintaining Skills
Patient harm can occur if staff are uncomfortable using medical equipment or performing a procedure, or are unaccustomed to an organization or care area’s processes. ECRI Institute has received reports of adverse events occurring because a health care professional was unfamiliar with equipment, such as infusion pumps and robotic-assisted surgical systems, or lacked competence with procedures and processes, ranging from Foley catheter insertion to management of a hemorrhaging patient after childbirth.
#8 Early Recognition of Sepsis across the Continuum
Sepsis can be difficult to detect, but early recognition is vital because sepsis can quickly turn deadly. Health care workers throughout the continuum of care must be able to recognize sepsis. Simulation and skills practice can help workers recognize sepsis and communicate their concerns. To facilitate timely diagnosis and management, health care organizations across the continuum should have protocols for response when sepsis is suspected, much as they do for chest pain. Organizations may use checklists, tools or algorithms to support the response.
#9 Infections from Peripherally Inserted IV Lines
Peripheral intravenous (PIV) catheters are commonly used items in health care. Often, PIVs are inserted upon admission as a matter of course, in case the patient needs IV therapy at a later point. However, PIVs can expose patients to a significant risk of infection – one that is underreported, under-recognized, and often ignored. Increased awareness of PIV-catheter-related infections, coupled with routine active surveillance and follow-up reporting, can help reduce the risk.
#10 Standardizing Safety Efforts across Large Health Systems
Regardless of organization size, the goal is to institute structures that effectively allow patient safety leaders to support organization leadership in engaging with patient safety priorities. Foundational principles of continuous communication up and down the chain of command, clear organizational structure, consistent committee configuration, and universal strategic planning and implementation can help the organization reduce inconsistencies and embed a strong focus on patient safety. As health systems grow and expand across the continuum, it is beneficial to leverage the protections that a patient safety organization (PSO) affords to all affiliated providers within the health system.
About the list
In selecting this year’s list, ECRI Institute relied both on data regarding events from our PSO database of more than 2.8 million event reports, as well as expert judgment. This list identifies concerns that might be high priorities for a range of reasons, such as new risks, existing concerns that are changing because of new technology or care delivery models, and persistent issues that need focused attention or pose new opportunities for intervention. We recommend that providers across the continuum use this list as a starting point for conducting patient safety discussions and setting priorities.
Download the executive brief at www.ecri.org/patientsafetytop10. The full report is available to members of many of ECRI Institute’s patient safety programs. If you would like more information, call (610) 825-6000, ext. 5891, or clientservices@ecri.org.