Health IT, Patient Identification, and Behavioral Health Issues Lead ECRI Institute's 2016 List of Top 10 Patient Safety Concerns

In selecting this year's list, ECRI Institute draws on its own large databases of reported safety events as well as the literature, and seeks out expert judgment. As a result, the list underscores that "these are real things that are happening," says Catherine Pusey, RN, MBA, associate director, ECRI Institute PSO. "They're happening at a serious level, our members are asking questions around these topics, and we're seeing them in many different manifestations."

This year's list includes:

1. Health IT configurations and organizational workflow that do not support each other
2. Patient identification errors
3. Inadequate management of behavioral health issues in non-behavioral-health settings
4. Inadequate cleaning and disinfection of flexible endoscopes
5. Inadequate test-result reporting and follow-up
6. Inadequate monitoring for respiratory depression in patients prescribed opioids
7. Medication errors related to pounds and kilograms
8. Unintentionally retained objects despite correct count
9. Inadequate antimicrobial stewardship
10. Failure to embrace a culture of safety

Topping the list this year is health information technology (IT) configurations and organizational workflow that do not support each other. When a health IT system is implemented, organizations need to tailor the configuration to the workflow and vice versa. But often, "after the implementation, people continue to do things the same way and really don't adjust the health IT system or their workflow," says Robert C. Giannini, NHA, CHTS-IM/CP, patient safety analyst and consultant, ECRI Institute. When health IT configuration and workflow clash, communication suffers.

During in-depth reviews of reported Patient Safety Organization (PSO) events, ECRI Institute analysts discovered that patient identification issues were not only frequent, but serious, and therefore this issue was ranked second on our list. ECRI Institute PSO is publishing a Deep Dive examining the topic in depth later this year.

Behavioral health issues in the non-behavioral-health setting, ranked third on this year's list. This concern is evident when hospital patients may behave aggressively due to psychiatric disorders, reactions to their treatment, or other reasons when not in the behavioral health unit. These circumstances can lead to injury or even death of patients or staff—as many recent media reports have shown. All staff need to be trained to work with patients with behavioral health needs and participate in frequent drills.

This list and associated guidance is intended to help healthcare organizations identify priorities and aid them in creating corrective action plans. ECRI Institute is providing free access to an executive brief of the report at www.ecri.org/PatientSafetyTop10. The full report, with additional strategies and resources, is available to members of ECRI Institute PSO and ECRI Institute's Healthcare Risk Control.

ECRI Institute encourages organizations to adapt relevant patient safety interventions to meet particular care setting. Although not all patient safety concerns on the list apply to all healthcare organizations, many are relevant to a range of settings across the continuum of care.

"Patients move fluidly between settings throughout their lives, which makes us interdependent in meeting each individual's healthcare needs," says Victor Lane Rose, NHA, MBA, CPASRM, operations manager for ECRI Institute's aging services risk management program.

For information about working with ECRI Institute PSO, visit www.ecri.org/pso, e-mail [email protected], call (610) 825-6000, ext. 5558, or write to us at 5200 Butler Pike, Plymouth Meeting, PA 19462. ECRI Institute's European office can be contacted at [email protected]; ECRI's Malaysian office can be contacted at [email protected]; and ECRI's Middle Eastern office can be contacted at [email protected].  

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About ECRI Institute

For nearly 50 years, ECRI Institute's work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. The ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving      the safety, quality, and cost-effectiveness of patient care. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit www.ecri.org. Find ECRI Institute on Facebook (www.facebook.com/ECRIInstitute) and Twitter (www.twitter.com/ECRI_Institute).

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