Each year, ECRI compiles our top 10 patient safety concerns. The list draws on our experience as a federally designated patient safety organization (PSO); ECRI and the ISMP PSO has reviewed more than 4 million reported events from acute, aging services and ambulatory care settings.
Our list reflects our review of root-cause analyses, coverage of the news, interactions with provider organizations and recommendations from an interdisciplinary expert panel.
Many of the items on this year’s list relate to COVID-19. While we remain hopeful that the pandemic is in its waning days, it has disrupted health care and our daily lives. It likewise laid bare some of the most entrenched problems in health care. By learning lessons from the pandemic, we can improve safety not just for this and future pandemics, but for all patient and resident care.
This year’s top 10 concerns are presented below.
Health disparities are health differences between different groups of people, such as differences in:
Racial disparities in health and health care will not disappear overnight and are not solely the responsibility of health care organizations, but health care organizations can begin taking actionable steps to start improving health equity. These steps include the following:
Emergencies often disrupt routine resident care and facility operations in long-term care. Aging services organizations should take an integrated systems approach to implement emergency response plans that concern residents, workforce and visitors. These plans should address:
Over the years, government investigations and other reports have warned that America’s health care system is woefully unprepared for a fast-moving infectious disease outbreak. COVID-19 has proved these warnings to be true.
Pandemic preparedness involves:
The COVID-19 pandemic severely strained health care supply chains, creating widespread shortages of key medical equipment and supplies, including ventilators, testing equipment and personal protective equipment such as masks, gloves and gowns.
To address these shortages, health care organizations have turned to nontraditional approaches, including off-label use of existing devices, expansion of device indications for use and use of nonmedical-grade equipment.
Tackling supply chain interruptions during emergencies and health crises requires planning, preparation, flexibility and cooperation with outside collaborators.
During the COVID-19 pandemic, supply chain disruptions and an increasing number of critically ill patients led to shortages in almost every drug class used for mechanical ventilation. Other crises have also led to drug supply shortages – for example, in September 2017, a shortage of IV saline bags occurred after Hurricane Maria damaged a key Puerto Rican manufacturing plant.
Drug shortages can result in:
Preparation, standardization, communication and monitoring are essential for safely managing drug shortages and reducing adverse events.
According to the American Hospital Association, the percentage of hospitals using telehealth increased from 35% in 2010 to 75% in 2017.
ECRI and the ISMP PSO reviewed a sample of 42 telehealth-related events and found several themes, including:
Telehealth is adding value-based care and ensuring greater access to meet patient demand. The challenge providers now face is continued expansion of services within in a safe environment.
For various reasons, providers may choose to modify or repurpose a medical device, workflow or system. However well-intended, such improvisation may lead to serious safety and regulatory compliance issues. Consider, for example, the following event submitted to ECRI and the ISMP PSO:
A COVID-19 positive patient was placed in a room with the ventilator outside the room to conserve personal protective equipment. While the nurse was connecting intravenous tubing through a hole in the wall, the heater plug on the ventilator circuit became disconnected. It took several seconds to reconnect the plug, potentially exposing staff to contagions.
In addition to having inspection and preventive maintenance programs, health care organizations should implement a risk management approach that documents equipment limitations, failures, user errors and improvisations that may affect patient care. Such data can better inform equipment decisions and thus alleviate the need to improvise.
Methotrexate is a folic acid antagonist that was originally approved to treat various cancers and is now used to treat some autoimmune diseases. When used for immunomodulation to treat such disorders, the drug is administered weekly.
Few medications are dosed weekly; thus, inadvertent daily dosing of oral methotrexate occurs in all stages of the medication use process – from prescribing to self-administration. Proper prescribing of methotrexate hinges on effective communication of instructions to patients, accurate documentation of dose and frequency, and accurate reflection of this information in computerized provider order entry systems.
Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices among inpatients. Severe cases of PIVC infection require intensive care or long-term care. They can lead to extended lengths of stay and antibiotic treatments – and even death. Other forms of harm include Phlebitis, infiltration, burns, leaks, redness, erythema, swelling and drainage problems.
The challenge of an effective harm prevention program is to reduce the rate of PICV infections as much as possible given a specific patient population. A multidisciplinary effort should involve leadership, those who allocate resources, infection control personnel, vascular access teams, those who insert and remove IVs, and patients themselves. Reporting these events to a PSO is essential.
Aerosol-generating procedures have always posed risks to health care workers, but COVID-19 has amplified them. Comparisons with two similar viruses, SARS and MERS, suggest that aerosolization of particles – and thus potential infection of clinicians during aerosol-generating procedures – is possible. The exposure risk of performing aerosol-generating procedures on suspected COVID-19 patients is very high.
Infection control leaders across the continuum of care should assess practitioners’ safety during aerosol-generating procedures and work to develop, implement and enforce appropriate precautions.
To download the full Top 10 Patient Safety Concerns report, with complete recommendations for each item, visit https://www.ecri.org/top-10-patient-safety-concerns-2021/
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