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A look back at the top 10 patient safety concerns for 2015

December 24, 2015
by Nicole Stempak, Associate Editor
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Half of the top patient safety concerns are new for 2015, and many involve technology, according to the second annual list compiled by the ECRI Institute, an independent nonprofit healthcare organization.

“ECRI Institute’s Top 10 Patient Safety Concerns for Healthcare Organizations 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,” writes William Marella, MBA, executive director of operations and analytics for ECRI Institute’s Patient Safety, Risk, and Quality Group in the executive summary. “Since we began collecting patient safety events in 2009 as a Patient Safety Organization (PSO), we have received nearly 500,000 event reports.

“Each event often describes a systems-related breakdown, or near failure, in the care process of the patients our members are committed to serving. Some of the events describe serious, preventable patient injuries or deaths.”

Patient Safety Concerns for 2015:

  1. Alarm hazards from inadequate alarm configuration policies and practices
  2. Data integrity failures form 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

The Institute noted overlapping priorities with another of its annual list, the Top 10 list of Health Technology Hazards: alarm hazards, data integrity, IV mix-ups and inadequate reprocessing of endoscopes and surgical instruments.

The overlap “shows the significance of healthcare technology as it impacts patient safety overall,” says James P. Keller, MS, president of health technology evaluation and safety for the ECRI Institute. “A big reason why technology shows prominently on the top 10 list of patient safety concerns is the growing complexity of technology and the increased reliance on technology in delivering healthcare.”

The list was compiled based on a review of patient safety event reports, research requests and root-cause analyses submitted to ECRI Institute PSO, federally certified under the Patient Safety and Quality Improvement Act (PSQIA). The Act allows healthcare organizations to voluntarily share their safety surveillance data to be aggregated and analysis.

Related: A list of technology hazards for 2016

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