MDDI Online is part of the Informa Markets Division of Informa PLC

This site is operated by a business or businesses owned by Informa PLC and all copyright resides with them. Informa PLC's registered office is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 8860726.

Top 10 Patient Safety Concerns in 2020

The ECRI Institute identified these issues as the biggest patient safety concerns in 2020. Can medtech help tackle them?

  • Released in conjunction with National Patient Safety Awareness week, ECRI Institute's Top 10 Patient Safety Concerns for 2020 raises the profile of safety issues that pose risks to patients and healthcare providers.

    The report relies on the analysis of more than 3.2 million patient safety events in ECRI's patient safety organization reporting program, as well as the judgement and experience of its interdisciplinary patient safety and medication safety experts.

    Proactively addressing many of the concerns on this list is an essential part of preventing the further spread of the coronavirus (COVID-19), the organization said.

    "Unsafe healthcare delivery harms millions of patients," said Marcus Schabacker, MD, PhD, president and CEO at ECRI. "Our annual patient safety report provides a roadmap to help healthcare leaders know what goes wrong and how to prevent harm."

    ECRI has developed a Coronavirus Outbreak Preparedness Center to help hospitals, health systems, ambulatory care, and aging services facilities protect workers, patients, residents, and the public as the threat of coronavirus reaches across the globe.

    Over the years, ECRI has witnessed other catastrophic events—including outbreaks of severe acute respiratory syndrome (SARS) and Ebola—and has learned lessons that are pertinent for dealing with current crises such as the outbreak of coronavirus, the organization noted.

    Image by Michal Jarmoluk on Pixabay
  • 1. Missed and delayed diagnoses

    When a diagnosis is missed or delayed, the patient might not get the treatment they need when they need it. When this happens, “we’ve missed a critical window,” says Sarah D. Creswell, patient safety analyst at the ECRI. Symptoms may go unchecked, and the condition may progress. Thus, missed and delayed diagnoses often result in more patient suffering and worse outcomes than if the condition had been diagnosed earlier.

    Accurate diagnosis requires the clinician to get a complete clinical picture of the patient’s relevant circumstances. It takes time to obtain an accurate history and perform a comprehensive physical, and clinician-patient communication is crucial, the authors note.

    “So much of diagnosis has to do with paying attention to the patient,” said Karen Schoelles, MD, vice president of clinical excellence and safety at the ECRI.

    The report says the electronic health record (EHR) should be structured so that clinicians and staff can readily understand the story so far: the trajectory of the patient’s condition, examinations and tests that have been performed, diagnoses that have been considered, and more. “Think how to virtually create a comprehensive and holistic view, how to put those pieces together,” says Schoelles.

    The authors also say that a healthcare organization’s culture should support open discussion of the diagnostic process and learning from diagnosis-related events. Education on cognitive heuristics and the diagnostic process can help illustrate how often all people take these mental shortcuts and emphasize techniques for avoiding common cognitive traps. The ability to discuss cases, brainstorm, and talk through the diagnostic process with providers who have the same or a different area of expertise can further support diagnosis. Ultimately, accurate diagnosis is a systems issue and everyone’s responsibility, according to the report.

    Image by Darko Stojanovic on Pixabay
  • 2. Maternal death rate

    The United States has the highest maternal death rate among the world’s developed nations, and it’s rising in the United States, even as it falls throughout most of the rest of the world, according to Carlye Hendershot, senior patient safety analyst and consultant at ECRI. Addressing alarming maternal health trends means prioritizing mothers’ safety across the continuum of care, according to the report.

    “What happens before, during, and up to one year after childbirth all play an important role in keeping moms safe and healthy,” Hendershot said.

    In fact, about two-thirds of pregnancy-related deaths occur in the postpartum period, with one-third concentrated in the later postpartum phase (one week to one year after delivery).

    “Therefore, all healthcare providers for women of childbearing age have an important role to play in ensuring their health and safety,” Hendershot said.

    According to the report, issues that impact maternal health in the United States include:

    • Racial and ethnic disparities 
    • Care coordination between ambulatory, specialist, and acute care settings 
    • Provider-patient communication and engagement 
    • Higher rates of risk factors (such as pregnancy later in life)
    • Access to quality care.
    Image by Pexels on Pixabay
  • 3. Behavioral health needs

    Healthcare workers face more violence than workers in any other industry, according to the report.

    "But we probably do the least about it,” said Nancy Napolitano, a patient safety analyst and consultant at the ECRI. “Part of this is because people fear what they don’t know. When you fear something, you either want to fight it or run from it. We have to understand people and how they work with their emotions.”

    This fear applies to both patients and clinicians. Patients may be in unfamiliar situations and may be off balance. Clinicians may see a patient with behavioral health issues and automatically raise their guard, the report says.

    Addressing these issues means recognizing patients’ behavioral needs sooner and more efficiently. The report emphasizes the importance of providers recognizing that just because a patient is demonstrating aggressive behavior, such as making violent threats or directing verbally abuse language toward a caregiver, it does not necessarily mean the patient has a mental illness. Organizations can improve their recognition of and response to behavioral health needs by providing education, training and retraining, behavioral health assessment for patients, improving rapid response teams’ response times by conducting drills, and instituting a culture change that begins with the organization’s leadership, the authors say.

    “We have these innate reactive responses to perceived dangerous situations,” Napolitano says. “Education and awareness can help stop caregivers’ reactive responses, and let them think and act rationally.”

    Image by Allie Smith on Pixabay
  • 4. Medical device problems

    According to the ECRI report, patient harm from medical devices occurred in 84 of every 1,000 admissions in one hospital. The authors emphasized the importance of providers responding to and learning from these incidents when they occur, and having a comprehensive plan for investigating device-related incidents.

    “Develop a plan to investigate a device-related incident now because eventually it will happen,” said Scott R. Lucas, director of accident and forensic investigation at ECRI.

    The organization should also have protocols for investigating incidents involving specific types of devices, equipment, or disposables, the authors said. Consider issues such as what data logs are kept, which accessories are included, how the equipment would be sequestered and tagged, additional devices or systems with which it interfaces, and what information must be documented and by whom, the report noted.

    Incidents involving medical devices or equipment can occur in any setting where they might be found, including aging services, physician and dental practices, and ambulatory surgery. The devices and domain-specific expertise available in these settings might differ from that of a hospital, but Lucas said the need for a plan is the same. These settings should identify individuals that have the skill set to coordinate investigations and those who can supply domain expertise, he recommends.

    Lucas likens this type of planning to devising a fire escape plan.

    "It’s about getting ahead of it,” he said. Then, when an incident occurs, “You just hit ‘go.’”

    Image by fernando zhiminaicela on Pixabay
  • 5. Improper device cleaning and reprocessing

    Incidents involving improperly reprocessed instruments can potentially result in devastating effects on patients, damage to organizational and provider reputations, citations and fines from regulatory bodies, prompt review by accrediting agencies, and lawsuits.

    "Patient safety starts in the sterile processing department,” said Gail Horvath, senior patient safety analyst and consultant at ECRI. "Everyone has a role.”

    ECRI recommends facilities establish effective workflows that involve the sterile processing department (SPD) and clinical staff input, incorporate quality checks throughout the sterilization process, improve interprofessional relationships, and provide continuing education opportunities for staff. Establishing relationships with instrument manufacturers and accessing resources from organizations such as the Association for the Advancement of Medical Instrumentation, the American Society for Health Care Engineering, and the Association of periOperative Registered Nurses can help fine-tune SPD policies and procedures to ensure timely and safe turnaround times, reduce preventable errors and associated costs, and ensure patient safety and satisfaction.

    6. Standardized safety concerns

    “For the longest time, culture of safety was dedicated to hospitals,” said Carol Clark, acting director of the ECRI patient safety organization. “Clearly, that never should have been the case. But now the denominators have swung exponentially toward ambulatory, long-term, and other healthcare settings and deserved attention is being paid to the culture of safety in these areas.”

    A merger may mark the first time an ambulatory or other facility comes under the umbrella of a larger organization, the authors note. Such facilities often must build their resources from scratch and they may lack the framework and infrastructure of larger organizations. But standardized culture of safety principles must be emphasized, implemented, and supported in smaller sites just as they are in the larger parent organizations.

    “No healthcare entity can do their work and fulfill their mission without having a culture of safety,” Clark said. “Building it from scratch requires education and practice so that it may be truly embraced.”

    7. Patient-EHR mismatches

    When a patient is not correctly matched with their electronic health record (EHR), duplicate and overlay records are created. Why is that a problem? Robert Giannini, patient safety analyst and consultant at ECRI, explains.

    “Overlay happens when one patient’s information is documented in another patient’s record. It can create errors that impact everything from medication administration to lab testing,” Giannini said. “These errors cause significant downstream safety effects.”

    Therefore, strong matching practices should be applied in EHR systems, prescription drug monitoring programs (PDMPs), health information exchanges (HIEs), and other digital health technologies, to allow for the flow of correct patient information across the continuum of care.

    Within one organization, a duplicate chart or overlay error is contained, said Lorraine Possanza, program director of Partnership for Health IT Patient Safety at ECRI. But if the record or records in question are part of an HIE, the potential for compounding the error is exponential, she says. That's when misinformation spreads throughout the exchange, needed care may be hindered, and errors are more difficult to correct the longer they go undetected, she explained.

    8. Antimicrobial resistance

    Antibiotics are still being prescribed unnecessarily, when no longer needed, in the wrong dose, and with the wrong indication—any of which can increase antimicrobial resistance, according to the report. Many of these antibiotics are being prescribed in care settings such as long-term care organizations, urgent care centers, and dentist offices.

    As antimicrobial resistance increases, treatment options become limited for affected patients, placing the public at large at risk.

    “These bugs are smarter than we are. They adapt,” said James Davis, senior infection prevention and patient safety analyst/consultant at ECRI. “We need antibiotics to work when we need them. We are getting these extremely resistant, extremely contagious pathogens, and we need to be able to treat the infected patients, not only for the benefit of the patients, but for the benefit of those around them.”

    To combat antimicrobial resistance, Davis recommends that hospitals, long-term care settings, and outpatient settings evaluate their antimicrobial stewardship programs to ensure that they align with current guidelines and recommendations, and verify that staff are following best practices. In addition, because so many antibiotics are being prescribed outside the acute care setting, Davis says care settings work together to ensure that best practices are being implemented across the continuum of care.

    9. Overrides of automated dispensing cabinets (ACDs)

    The widespread adoption of automated dispensing cabinents in pharmacies has greatly improved medication safety, according to the report. However, when overrides are used to remove medications from the ADC before pharmacist review and approval, it can lead to dangerous—even deadly—consequences for patients, the authors note.

    “The issue with ADC overrides is that you have access to more medication than is specifically ordered,” said Stephanie Uses, a patient safety analyst and consultant at ECRI. “It is easy to choose the wrong medication or the wrong dose of the medication and administer it to the patient.”

    Uses explains that overrides are a safeguard designed for emergency situations, when certain medications may be needed immediately and there is no time to seek the approval of a pharmacist. But not every medication needs to be "on override," she said.

    10. Fragmentation across care settings

    Similar to standardized safety concerns, the final concern on the list involves the fragmentation across care settings as healthcare delivery become increasingly complex.

    The report uses therecent emergence of urgent care centers and retail pharmacy care clinics as an example.

     “There is an opportunity to get faster care, but it may cause more fragmentation if there is no process to communicate findings to the patient’s primary care physician,” said Jean Harpel, operations manager of aging services at ECRI.

    Fragmentation can occur from one provider setting to another, as well as within a healthcare facility from one unit or department to another, according to the report.

    To compare this year's top patient safety concerns with last year's concerns, click here.

    For more information about the Top 10 Patient Safety Concerns of 2020, download the free report here.

    Photo by Olga Kononenko on Unsplash
Filed Under
500 characters remaining