Alarms, Health IT and Patient Violence Lead ECRI Institute’s 2015 Top 10 Patient Safety Concerns

PLYMOUTH MEETING, Pa. — Patient safety is a top priority for every healthcare organization, but knowing where to direct initiatives can be daunting. To help organizations decide where to focus their efforts, ECRI Institute has compiled its second annual list of the Top 10 Patient Safety Concerns for Healthcare Organizations.

“This is more than just a list; it’s a reminder that, despite the attention given to patient safety over the last 15 years or so, we can do better,” states William Marella, MBA, executive director of operations and analytics, ECRI Institute Patient Safety Organization. “Healthcare providers, regardless of what setting they practice in, can start with our top 10 list of patient safety concerns and use it to guide their own discussions about patient safety and improvement initiatives.”

This year’s list includes:

1. Alarm hazards: inadequate alarm configuration policies and practices
2. Data integrity: incorrect or missing data in EHRs and other health IT systems
3. Managing patient violence
4. Mix-up of IV lines leading to misadministration of drugs and solutions
5. Care coordination events related to medication reconciliation
6. Failure to conduct independent double checks independently
7. Opioid-related events
8. Inadequate reprocessing of endoscopes and surgical instruments
9. Inadequate patient handoffs related to patient transport
10. Medication errors related to pounds and kilograms

Topping the list is alarm hazards from inadequate configuration policies and practices. In recent years, much of the literature has focused on alarm fatigue—a condition that can lead to alarms missed by providers who are overwhelmed by, distracted by or desensitized to the multiple alarms that activate.

In this new patient safety concerns list, ECRI Institute encourages healthcare institutions to look beyond alarm fatigue. “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, ECRI Institute. “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.”

Health IT is on ECRI’s list again this year, focusing on data integrity from incorrect or missing data in EHRs and other health IT systems. Health information technology offers numerous potential benefits, but it can create new safety risks if it is not designed appropriately, implemented carefully and used thoughtfully.

Patient violence, ranked third on this year’s list, discusses the challenges hospitals face affecting the safety and well‐being of staff, patients and visitors. The range and impact of patient violence across the hospital is not limited to incidents that make the headlines. Clinical staff may feel abandoned and left without the resources to do their jobs safely, given the frequency with which they must manage violent behavior in patients—at least 15 incidents a day, according to one PSO member hospital.

To compile its list of patient safety concerns, ECRI Institute PSO reviewed its database of patient safety events, root-cause analyses and custom research requests submitted throughout the year by healthcare organizations and its partner PSOs, as well as sought guidance from its team of experts.

This list and associated guidance is intended to help healthcare organizations identify priorities and aid them in creating corrective action plans. ECRI Institute is providing free access to the list at www.ecri.org/PatientSafetyTop10.