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Top 10 Patient Safety Concerns in 2019

The ECRI Institute identified these issues as the biggest patient safety concerns in 2019. Can medtech help tackle them?

  • Released in conjunction with National Patient Safety Awareness week, ECRI Institute's Top 10 Patient Safety Concerns for 2019 raises the profile of safety issues that pose risks to patients and healthcare providers.

    In selecting this year’s list, ECRI Institute said it relied both on data regarding events and concerns and on expert judgment. Since 2009, when ECRI's patient safety organization (PSO) began collecting patient safety events, the institute and its partner PSOs have received more than 2.8 million event reports.

    "That means that the 10 patient safety concerns on this list are very real," noted the authors of the report. "They are harming people, sometimes seriously."

    The process synthesized data from these varied sources: a review of events in the ECRI Institute PSO database; PSO members’ root-cause analyses and research requests; topics reflected in weekly HRC Alerts; and voting by a panel of experts from inside and outside ECRI Institute.

    The authors also noted that the development of the list was not an exercise in simple tabulation, meaning that it does not necessarily represent the issues that occur most frequently or are most severe.

    "Most organizations already know what their high-frequency, high severity challenges are," the authors said. "Rather, this list identifies concerns that might be high priorities for other 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."

  • 1. Diagnostic Stewardship and Test Result Management Using EHRs

    Providers have begun relying on electronic health records (EHRs) to help with clinical decision support, to track test results, and to flag issues, but the report authors point out that EHRs are only part of the solution.

    Technology is just a tool—there’s currently not an algorithm that is going to identify all the key elements and analyze them to give you the correct diagnosis,” said Lorraine Possanza, program director for the Partnership for Health IT Patient Safety.

    According to Patricia Stahura, a senior analyst and consultant for the ECRI Institute, three key components must be clearly communicated in the EHR: the diagnosis, the treatment plan, and the follow-up plan.

    “The information must be accurate and must be written so that future clinicians looking at the EHR can understand it,” Stahura said. “If you have faulty information or missing test results, you are predisposed to making a diagnostic error.”

  • 2. Antimicrobial Stewardship in Physician Practices and Aging Services

    “We need to combat antibiotic resistance before the situation gets worse,” said Stephanie Uses, a patient safety analyst and consultant for the ECRI Institute PSO. She noted that not many recently-approved drugs are antibiotics and that as antibiotic resistance increases, treatment options become more limited.

    The report authors suggested that perhaps the most significant challenge facing antibiotic stewardship is managing patient expectations. Patients expect an antibiotic to help them feel better. And as any clinician can attest to, this has led to antibiotics being overprescribed, which has contributed to the problem of antimicrobial resistance.

    “Patients need to feel like they are being taken care of, even without a prescription for an antibiotic,” explains Sharon Bradley, senior infection prevention and patient safety analyst and consultant for the ECRI Institute. “Instead, give them a prescription for what to do, what to watch for. Follow up with them. Everyone needs to know their role: the physician needs to know what to do, and the patient needs to know what to do.”

    “Antibiotic stewardship does not mean withholding necessary treatment,” Bradley said. “But we have casually and cavalierly handed around the candy dish of antibiotics without a second thought as to how we may be harming our patients.”

  • 3. Burnout and Its Impact on Patient Safety

    When doctors, nurses, and other healthcare workers experience burnout, it has a negative impact on patient care and safety. 

    “Healthcare providers tend to be self-critical, high functioning, and very motivated,” said Ellen Deutsch, MD, medical director for the ECRI Institute. “They will increase demand on themselves and have high expectations for their own performance, which is laudable, but it can also be problematic.”

    The ECRI report identifies the electronic health record as a contributing factor, but the authors note that burnout goes beyond providers’ frustrations with documentation.

    Reprioritizing what a clinician needs to do is one way to reduce burnout, but ultimately the system must change, according to the report. 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, the authors said. Providers need to be treated as human beings, whose opinions and abilities are valued, rather than as cogs in a wheel.

  • 4. Patient Safety Concerns Involving Mobile Health

    Mobile health technology opens up a world of opportunities by transporting healthcare from traditional settings into the home, according to the report. But the authors note that this technology also opens up a world of risks like the lack of regulation, 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 even at all.

    “The measurement itself may be working, but how well does it work in the real world?” asks Juuso Leinonen, senior project engineer of the Health Devices Group at the ECRI Institute. “Part of that goes to usability. It has to be almost foolproof.”

    Methods for informing clinicians about user error and inactivity must be established, the authors said. Along with assessing ease of use, organizations must identify the right candidates for mobile health, and provide training for both providers and patients on how to use a device.

    “It’s no use to have a technology that the patient is supposed to use at home if the patient is not going to use it,” Leinonen said.

  • 5. Reducing Discomfort with Behavioral Health

    According to Nancy Napolitano, a patient safety analyst at the ECRI Institute, people working with individuals with behavioral needs fear what they don't know, and fear can make them react defensively. This fear can also lead providers and staff to behave in ways that fail to meet patients' needs, and sometimes it can even escalate situations, she said.

    In many healthcare settings, behavioral and physical health are siloed, the report points out. But people with behavioral health needs are in every setting, and it is not always obvious when an individual has such needs.

    “How do we change our mindset so that everyone belongs here and is treated with dignity and respect?”

    The answer, according to the report, lies in communication skills, specialized training, and opportunities to practice.

    “The only way not to be afraid of something is to experience it positively over and over again,” Napolitano said.

  • 6. Detecting Changes in a Patient's Condition

    “Transitions of care and handoffs are critical times for care delivery, and they’re fraught with danger,” said Mary Rodger, a senior risk management analyst and a consultant for the ECRI Institute. “Passing along and receiving the correct information sets providers up for success.”

    Technology can alert caregivers to a patient’s changing condition, but it must be used appropriately, according to the report. Staff must be trained in how to operate the equipment and understand the organization’s policies and their responsibilities for responding to alarms. Finally, staff must listen to concerns that patients and family members raise.

  • 7. Developing and Maintaining Skills

    According to the report, the ECRI Institute has received reports of adverse events occurring because a healthcare 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.

    One solution, according to the report, is simulation training.

    Simulation training replicates real-life scenarios and offers an ideal opportunity for health professionals to practice their skills. “Simulation poses no risk of direct harm to patients, and they can be designed for individuals to practice and learn technical skills or for healthcare teams to conduct situational drills, the authors noted.

  • 8. Early Recognition of Sepsis Across the Continuum

    In recent years, sepsis has gained attention in acute care. But as healthcare delivery changes, it's important to move that early recognition of sepsis outside the hospital, according to James Davis, senior infection prevention and patient safety analyst and a consultant at the ECRI Institute.

    The authors suggest that healthcare workers throughout the continuum of care must be able to recognize sepsis. That means training certified nursing assistants to use screening tools, and encouraging physician practices to screen for sepsis in the exam room and over the phone, the authors said.

    They also suggested that organizations use checklists, tools, or algorithms to support the response to sepsis. Another key, according to the report, is sharing information across the continuum. For example, knowing that an individual normally has only mild confusion can help providers suspect sepsis when that person seems very confused.

    Because hospital readmissions are concerns for both hospitals and nursing facilities, the report authors suggest that hospitals and nursing facilities collaborate to address problems.

  • 9. Infection from Peripherally Inserted IV Lines

    Peripheral intravenous catheters (PIVs) can expose patients to a significant risk of infection, and according to the ECRI report, it's one that is underreported, underrecognized, and often ignored.

    “Any time you break the skin, you’re breaking down the body’s first line of defense against infection,” Davis said. “Patients might not need a peripheral line, but your staff might put one in just because the patient is admitted and they may need it at some point. Staff may say, ‘Well, it’s only going to be in for an hour or two,’ not realizing that that’s enough time for an infection to develop.”

    To reduce the risk, he suggested increased awareness of PIV-catheter-related infections, plus routine active surveillance and follow-up reporting.

  • 10. Standardizing Safety Efforts Across Large Health Systems

    According to Shelia Rossi, manager of the ECRI Institute patient safety organization (PSO), healthcare organizations are becoming nationwide "megasystems," which raises concern about keeping patient safety at the forefront.

    Rossi said processes such as reporting and quality initiative prioritization that require careful attention can hinder safety efforts if not thoughtfully implemented. 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, the report authors said. 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.

    The authors also suggest that healthcare systems leverage the protections of a PSO.

    The Patient Safety and Quality Improvement Act of 2005 (PSQIA) enables all licensed or certified healthcare facilities and clinicians to participate in a PSO and take advantage of the privilege and confidentiality protections it affords. For health systems with providers across multiple states, the protections afforded under PSQIA are uniform nationwide, according to the report.

    For more information about the Top 10 Patient Safety Concerns of 2019, download the free report here.

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