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With data from 1,000 hospitals coming in regularly, top 10 lists are probably easy to create for ECRI Institute PSO, a Plymouth Meeting, PA-based PSO and research organization. The latest by the organization is a Top 10 Patient Safety Concerns report, released in April.
Karen Zimmer, MD, MPH, FAAP, the medical director of the patient safety, risk, and quality group, says this list was created as a compliment to ECRI Institute’s Top 10 Technology Hazards list, which was released at the end of 2013. (See the December 2013 issue of Hospital Peer Review, page 133.) "We have been collecting PSO data since 2009 and have more than 300,000 events in our database," she says. "We thought it was really important to share some of the recurring themes and tell organizations what we think they should be looking at, and consider what they might need to modify."
The issues aren’t new for the most part, she says, aside from health IT and drug shortages, which are relatively new on the landscape. "But then again, with IT, that is because health IT was still new on the landscape five years ago. Now that data integrity failure is here, we expect it to decline over time."
The list of 10 was pared down from 20, based on the input of thought leaders and stakeholders from within and outside ECRI, says Cynthia Wallace, a risk management analyst at ECRI. While some may be there because numerically there were a lot of the 300,000 events related to them, the list is also based on root cause analyses and research requests that come to the PSO.
"It’s not always what’s most common that captures our attention," Wallace explains.
Zimmer says that organizations may find their priority lists may differ from ECRI’s, but that just about every institution is going to see most of these resonating with them. The differences will be in what order you tackle them.
"Retained foreign objects, falls — these things are almost universal across organizations," says Wallace. But there will be nuances. For example, in retained objects, don’t limit yourself to looking in the surgical suites. Look in other interventional areas for retained objects, as well. Similarly, with falls, don’t limit yourself to the usual approaches. (For some new ideas, see story page 69.)
None of these issues is as straightforward as it may seem, either, says Zimmer. "If it was something simple, with one solution, we would have fixed it. These issues are multifactorial."
And just because you have this top 10 list, don’t limit yourself. The 10 that didn’t make it included other important items, such as device-related pressure, ED throughput, and tubing-line mix-ups. The full list is:
1. data integrity failures with health information technology systems;
2. poor care coordination with patient’s next level of care;
3. test results reporting errors;
4. drug shortages;
5. failure to adequately manage behavioral health patients in acute care settings;
6. mislabeled specimens;
7. retained devices and unretrieved fragments;
8. patient falls while toileting;
9. inadequate monitoring for respiratory depression in patients taking opioids;
10. inadequate reprocessing of endoscopes and surgical instruments.
Numbers one, seven and 10 were also on the top 10 technology hazards list.
The complete list and accompanying report can be downloaded free with registration at the ECRI website, www.ecri.org.
For more information on this topic, contact:
• Karen P. Zimmer, MD, MPH, FAAP, Medical Director, Patient Safety, Risk, & Quality Group, ECRI PSO, Plymouth Meeting, PA. Telephone: (610) 825-6000
• Cynthia Wallace, Senior Risk Management Analyst, Patient Safety, Risk, & Quality Group, ECRI, Plymouth Meeting, PA. Telephone: (610) 825-6000