Top 10 patient safety concerns for 2017, according to ECRI

A new report says poor information management and faulty CDS implementation pose risks to patients. It also raises concerns about patient identification and process improvement activities.
By Mike Miliard
01:10 PM

Health information technology holds enormous potential for improving patient safety, but only when implemented and used correctly. A new study from ECRI Institute spotlights EHR information management practices and clinical decision support as two areas of particular concern.

"The 10 patient safety concerns listed in our report are very real," says Catherine Pusey, RN, associate director, ECRI Institute Patient Safety Organization. "They are causing harm – often serious harm – to real people."

This list for 2017, which derives from PSO event data, focuses on concerns raised by provider organizations and ECRI experts:

  1. Information Management in EHRs
  2. Unrecognized Patient Deterioration
  3. Implementation and Use of Clinical Decision Support
  4. Test Result Reporting and Follow-Up
  5. Antimicrobial Stewardship
  6. Patient Identification
  7. Opioid Administration and Monitoring in Acute Care
  8. Behavioral Health Issues in Non-Behavioral-Health Settings
  9. Management of New Oral Anticoagulants
  10. Inadequate Organization Systems or Processes to Improve Safety and Quality

With regard to EHR information management, ECRI said provider organizations should approach IT safety processes holistically: engaging with health information management experts, IT professionals and clinical engineers on patient safety and risk management programs.

Other strategies include ensuring that EHR end users understand the systems' capabilities and potential problems, according to ECRI, and that involves encouraging them to report any concerns to be followed up with accordingly. Engaging patients to help with integrity of their own health information could also be a boon to safety.

"Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible," said Lorraine Possanza, program director, Partnership for Health IT Patient Safety at ECRI.

Along those lines, implementation and use of clinical decision support rounded out the top three of the 2017 list. Tools to "ensure that the right information is presented at the right time within the workflow" can lead to be big improvements in quality, said Robert Giannini, patient safety analyst and consultant at ECRI.

If they're implemented incorrectly or used in the wrong way, however, those opportunities can be negated, resulting in patient harm.

The group says healthcare organizations should design CDS systems carefully, and suggests that providers avail themselves of guides published by ECRI, the Office of the National Coordinator for Health IT and others for best practices.

A multidisciplinary team should have oversight of CDS rollouts, and users should be trained to properly use specific systems, and health organizations should monitor the effectiveness and appropriateness of CDS continually – evaluating their impact on workflow, and reviewing staff response to alerts, then redesigning when necessary.

The 2017 report also highlighted patient identification as an "issue that most healthcare providers recognize as a significant problem,” according to William Marella, executive director, PSO operations and analytics at ECRI Institute.

Leaders should fully support patient ID initiatives, prioritizing the issue, engaging clinical and nonclinical staff and asking them to identify barriers to safe identification practices, the report suggested. Redundant processes for ID can decrease the likelihood of misidentification. Standardization of electronic displays and ID bands, and well-deployed barcoding systems can also help.

Number 10 on ECRI's list focuses on inadequate organizational systems and processes for quality and safety improvement.

"Numerous studies show a link between error prevention and a culture of safety," according to the report. "Nevertheless, healthcare organizations have been slow to adopt all the necessary features of a high-reliability organization. Proactive strategies can be used to examine processes, identify what can go wrong, and make the process less vulnerable to error before mistakes occur. Strong preventive strategies, such as standardization and automation, should be explored."

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