Top 10 Patient Safety Concerns for 2020

Missed and delayed diagnoses lead patient safety list developed by the ECRI Institute.

In addition to issues related to the novel coronavirus, ECRI has identified 10 top patient safety concerns for 2020.

Twenty years after publication of the Institute of Medicine's landmark report To Err is Human: Building a Safer Health System, patient safety remains a significant concern for the healthcare sector. The Institute of Medicine report estimated 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.

The scope of ECRI's top 10 patient safety concerns for this year is broad, the executive brief of the report says. "This top 10 report highlights patient safety concerns across the continuum of care because patient safety strategies increasingly focus on collaborating with other provider organizations, community agencies, patients or residents, and family members. Each patient safety concern on this list may affect more than one setting."

ECRI has been gathering patient safety event data through its patient safety organization, ECRI PSO, since 2009. "We and our partner PSOs have received more than 3.2 million event reports. This means that the 10 patient safety concerns on this list are very real. These concerns are harming people—sometimes seriously," the executive brief says.

1. Missed and delayed diagnoses can result in worse outcomes than timely diagnosis. "Accurate diagnosis requires the clinician to get a complete clinical picture of the patient’s relevant circumstances. It takes time to obtain an accurate history and perform a comprehensive physical, and clinician-patient communication is crucial," the executive brief says.

The electronic health record (EHR) can play a key role in the diagnosis process such as tracking the trajectory of a patient's condition and cataloging examinations and test results.

2. Maternal health is a pain point in the United States, which lags the industrialized world in this healthcare category. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.

"Issues that impact maternal health in the U.S. include racial and ethnic disparities; care coordination between ambulatory, specialist, and acute care settings; provider-patient communication and engagement; higher rates of risk factors (such as pregnancy later in life); and access to quality care," the executive brief says.

3. Early recognition of behavioral health needs is an essential factor to reduce workplace violence in healthcare settings. About three-quarters of U.S. workplace assaults occur in healthcare settings, according to a report by the Occupational Safety and Health Administration.

Violent or threatening behaviors in patients are often not related to mental illness, the executive brief says. "Organizations can improve their recognition of and response to behavioral health needs by providing education, training and retraining, behavioral health assessment for patients, improving rapid response teams' response times by conducting drills, and instituting a culture change that begins with the organization's leadership."

4. Responding to and learning from device problems requires a comprehensive plan to investigate device-related incidents, the executive brief says. "The organization should also have protocols for investigating incidents involving specific types of devices, equipment, or disposables. Consider issues such as what data logs are kept, which accessories are included, how the equipment would be sequestered and tagged, additional devices or systems with which it interfaces, and what information must be documented."

5. Device cleaning, disinfection, and sterilization is generally the responsibility of sterile processing departments. SPDs face several barriers such as productivity pressure, lack of supplies, and communication problems with the departments they serve.

"ECRI recommends facilities establish effective workflows that involve SPD and clinical staff input, incorporate quality checks throughout the sterilization process, improve interprofessional relationships, and provide continuing education opportunities for staff," the executive briefing says.

6. Standardizing safety across healthcare organizations is challenging in this era of mergers and acquisitions, the briefing says. "The modern healthcare system stretches beyond hospital walls, across the continuum of care, and across state lines. A system's culture of safety must have the same reach. As the expansion of health systems continues, organizations find themselves facing many settings with differing cultures, processes, and resources."

Solutions include education as well as standardizing policies, processes, and procedures.

7. Patient matching in the EHR is essential to avoid creating duplicate records as well as overlay records, which occurs when one patient's information is included in another patient's record. "Strong matching practices should be applied in EHR systems, prescription drug monitoring programs (PDMPs), health information exchanges (HIEs), and other digital health technologies, to allow for the flow of correct patient information across the continuum of care," the executive briefing says.

8. Antimicrobial stewardship fights antimicrobial resistance, which limits treatment options for patients. "Despite the increased focus on the importance of antimicrobial stewardship in healthcare, and increased recognition among healthcare workers and patients alike, antibiotics are still being prescribed unnecessarily, when no longer needed, in the wrong dose, and with the wrong indication," the executive brief says.

9. Overrides of automated dispensing cabinets (ADCs), which control access to medications, can put patients at risk when overrides circumvent pharmacist review and approval. Overrides are designed for emergency situations, when medications are needed immediately. Measures to ensure patient safety include medication safety committee review of whether ADC override access is appropriate and retrospective pharmacist review of overrides, the executive brief says.

10. Fragmentation across care settings is a patient safety concern because there are multiple clinical settings for care delivery, the executive brief says. "Breakdowns in care from a fragmented healthcare system can lead to readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and general patient and provider dissatisfaction."