For the past few years, we’ve highlighted the ECRI Institute’s annual Top 10 Health Technology Hazards report, which provides an overview of new and old technology hazards for health care facilities to keep in mind (read this year’s post here).
Now ECRI has released a new report entitled “Top 10 Patient Safety Concerns for Healthcare Organizations.” The goal of the list, according to ECRI, is to “give healthcare organizations a gauge to check their track record in patient safety.” The list, which will be published on an annual basis, draws upon more than 300,000 patient safety events, custom research requests, and root-cause analyses submitted to the institute’s federally designated patient safety organization (PSO) for assessment. A selection from the top 10 can be found below.
Poor care coordination with a patient’s next level of care
The concern: Gaps in communication about patient care—for example, between hospital and provider, among providers, and between long-term care settings and hospitals—have been reported to ECRI’s PSO. And while it is best practice for hospitals to send a patient’s discharge information to all of a patient’s providers, this doesn’t always happen.
Some suggestions: On reason information doesn’t get passed on, according to the report, is that staff aren’t always able to identify a patient’s other providers. One strategy suggested by the report is for practices to provide current contact information, such as phone and fax numbers, on their Web sites. Electronic health records can facilitate care communication among providers, but the report stresses that organizations must establish procedures that address accessing, reviewing, and acting on the findings in those records.
Failure to adequately manage behavioral health patients in acute care settings
The concern: Despite the fact that patients’ mental health needs must be addressed in addition to their clinical needs when presenting in an acute care setting or ED, events reported to ECRI’s PSO suggest this isn’t always the case. Of particular concern is the incidence of patient violence in these settings.
Some suggestions: One issue that has been raised is that caregivers and staff may not recognize the warning signs of imminent violence when a patient is being evaluated (this can include shouting, demanding behavior, physical restlessness and tension, and excessive fear or paranoia). The report also highlights the need for more attentiveness to behavioral health issues overall and the need to bridge the gap between acute and behavioral health care.
Patient falls while toileting
The concern: Patient falls are among the top safety events reported to ECRI’s PSO, and represent around one-quarter of all events in the PSO event report database. Falls that occur while a patient is toileting are of particular concern, raising the added challenge of balancing a person’s privacy needs with safety.
Some suggestions: According to the report, nurses can ask patients during rounding if they need to use the bathroom, using the specific phrase “do you want to go now or the next time I come in?” Patients at higher risk for falls can also be clustered closest to the nurses’ station. Lastly, an organization’s fall prevention program should include nightly toileting rounds.
Inadequate monitoring for respiratory depression in patients taking opioids
The concern: The increased use of opioids carries with it an increased risk of adverse events. One of the most serious of these is respiratory depression. This is often preceded by sedation.
Some suggestions: According to the report, facilities should educate staff on assessing patients at risk for respiratory depression and recognizing the signs of opioid toxicity. High-risk patients include very young or elderly patients, patients with sleep apnea, and patients who are morbidly obese. Nurses caring for patients taking opioids should be aware of other sedating drugs the patient might be taking, which could increase the risk of respiratory depression. The report also suggests nurses administering opioids use a four-point scale called the “Pasero Opioid-Induced Sedation Scale” to assess the patient’s condition and determine whether intervention is needed if the patient is frequently drowsy.
Other safety concerns in the 2014 list include test results reporting errors, mislabeled specimens, and drug shortages. Some safety concerns on the list also appeared on the 2014 health technology hazards top 10. These repeat offenders include the following:
- inadequate reprocessing of endoscopes and surgical instruments
- retained devices and retrieved fragments
- data integrity failures with health information technology systems
You can access the full report here.—Amy M. Collins, editor