EHRs pose risks
Health IT holds great promise for improving care but can also pose big risks when not properly deployed. ECRI Institute's second annual list of patient safety concerns puts EHR-related worries in the top two spots.
"This is more than just a list," says William Marella, executive director of operations and analytics of the ECRI Institute Patient Safety Organization, in a press statement. "It's a reminder that, despite the attention given to patient safety over the last 15 years or so, we can do better."
Access ECRI's full report here.
Alarm Hazards: Inadequate Alarm Configuration Policies and Practices
While the dangers of alarm fatigue are well-known, ECRI urges providers to pay attention to more systemic – and potentially much more dangerous – problems that are often overlooked.
"In addition to missed alarms that can result from excessive alarm activations, hospitals also have to be concerned about alarms that don't activate when a patient is in distress," says Rob Schluth, senior project officer at ECRI Institute and the lead project manager for the Top 10 Health Technology Hazards for 2015 project, in a statement.
"In our experience, alarm-related adverse events – whether they result from missed alarms or from unrecognized alarm conditions – often can be traced to alarm systems that were not configured appropriately," he said.
Data Integrity: Incorrect or Missing Data in EHRs and Other Health IT Systems
This problem was also listed on ECRI's Top 10 Health Technology Hazards report.
"With the introduction of any new technology, we need to identify and respond to novel problems it presents as well as old problems that the new technology doesn't eliminate," says Marella.
While data integrity issues surely exist with paper medical records as well,"as EHRs become more interoperable, incorrect information is more readily available, more easily shared and harder to eliminate," he says. "In order to get a return on the investment we've made in EHRs and clinical decision support, we now need to tackle the more mundane problem of making sure the data in the EHR is accurate."
Managing Patient Violence
Hospitals are regularly faced with violent or threatening patients whose behavior could jeopardize the safety of patients and staff.
But clinical staff often lack training in behavioral health and miss or mishandle the behavioral cues that might signal imminent violence, according to Ruth Ison, patient safety analyst/consultant at ECRI Institute PSO.
Mix-Up of IV Lines Leading to Misadministration of Drugs and Solutions
Sometimes called "spaghetti syndrome" the tangle of tubes, catheters and cables at the bedside "make it harder to track the source of an IV line as it leads from the patient's insertion site to the original source," says James P. Keller, vice president, health technology evaluation and safety at ECRI Institute.
Care Coordination Events Related to Medication Reconciliation
During admissions, transfers and discharges, "the patient's medications should be reconciled to ensure the patient is on the correct medications for the next phase of care," says Mary Beth Mitchell, RN, patient safety analyst and consultant at ECRI Institute PSO. Inadequate medication reconciliation puts patients at risk for medication errors, inadequate follow-up care and hospital readmissions.
Failure to Conduct Independent Double Checks Independently
"Nobody in the universe would think of doing a blood transfusion without doing an independent double check first because you could kill the patient pretty quickly," says Elizabeth Drozd, patient safety analyst, ECRI Institute PSO. "But for high-alert medications, we've seen a lot of controversy about doing independent double checks and have seen a lot of failures in that process."
"The use and the prescribing of opioids has significantly increased in recent years," says Stephanie Uses, patient safety analyst, ECRI Institute PSO.
HHS' National Action Plan for Adverse Drug Event Prevention shows that the number of prescription opioids dispensed doubled between 1999 and 2010; by the end of that period, the number of related deaths exceeded the number of overdose deaths involving heroin and cocaine combined. Meanwhile, the number of ED visits related to opioid misuse and abuse totaled more than 420,000 in 2011 – double the number in 2004, according to ECRI.
Inadequate Reprocessing of Endoscopes and Surgical Instruments
"We continue to see reprocessing issues in our accident investigations" and in media reports, says Schluth.
Hospitals reprocess countless surgical instruments and devices every day for subsequent use. Not only are the devices difficult to clean, but "multiple steps are required to get it right," adds Keller.3>
Inadequate Patient Handoffs Related to Patient Transport
"Transporting a patient within the hospital to another clinical setting or between units within the facility presents risk of harm to the patient and, depending on the needs of the patient, can be an unsettling experience for nurses charged with caring for the patient, and for the transporter," says Kelly Graham, RN, patient safety analyst at ECRI Institute PSO.
Medication Errors Related to Pounds and Kilograms
"We definitely see these events in the PSO data," says Sheila Rossi, patient safety analyst/consultant at ECRI Institute PSO.
But confusion between pounds and kilograms isn't limited to hospitals; it can happen "anyplace that has a scale," she adds.
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November 25, 2020
November 25, 2020