ECRI Institute Highlights Root Causes for Serious Patient Safety Events

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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 first annual list of the Top 10 Patient Safety Concerns for Healthcare Organizations.

With the federal government offering financial incentives for hospitals and physician practices to adopt electronic health records (EHRs), it is no surprise that health IT is the No. 1 item on this year’s list. What is surprising, says ECRI Institute, is the specific risk from the integrity of data in health IT systems. While appropriately designed and implemented systems can support patient safety and quality of care, incorrect data can lead to patient harm. ECRI Institute addressed the same concerns with health IT in its Top 10 Health Technology Hazards for 2014.

Poor care coordination, drug shortages, and mislabeled specimens made ECRI Institute’s list, as well as falls while toileting and foreign objects unintentionally retained after surgery, childbirth, or other interventional procedures. ECRI Institute’s analysis reveals specific contributing factors that can lead to greater occurrences of these events. This awareness enables organizations to spend their patient safety effort in ways most likely to reduce patient harm and therefore the costs of care.

“In a time of competing priorities and limited resources in healthcare, we encourage facilities to use the list as a starting point for patient safety discussions and for setting their patient safety priorities,” says Karen P. Zimmer, MD, MPH, FAAP, medical director of ECRI Institute’s patient safety, risk, and quality group and of ECRI Institute Patient Safety Organization (PSO). “ECRI Institute PSO has been collecting and analyzing events since 2009 and there are sufficient data to share recurring themes and associated prevention strategies.”

This list is intended to help healthcare organizations identify priorities and aid them in creating corrective action plans. ECRI Institute is providing free access to a number of educational tools at www.ecri.org/PatientSafetyTop10, including: full report, a PowerPoint slideshow that summarizes the Top 10, and a poster.

“The events reported to us give us a deeper understanding that an event we’re seeing in one organization, we’re also seeing in others,” says Catherine Pusey, RN, MBA, manager of clinical analysts at ECRI Institute PSO. “Included with this report are recommended risk mitigation strategies for these issues. Individuals in risk and quality departments can present this information to their organization’s leadership to get the resources they need to improve safety.”

Source: ECRI Institute



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