Device cleaning, disinfection and sterilization also made the list
ECRI Institute names diagnostic errors the No. 1 concern on its 2018 Top 10 Patient Safety Concerns for Healthcare Organizations. Each year, approximately 1 in 20 adults experiences a diagnostic error, according to published studies. These errors and delays can lead to care gaps, repeat testing, unnecessary procedures, and patient harm.
“Diagnostic errors are not only common, but they can have serious consequences," says Gail M. Horvath, MSN, RN, CNOR, CRCST, patient safety analyst, ECRI Institute. "A lot of hospital deaths that were attributed to the normal course of disease may have been the result of diagnostic error."
ECRI Institute suggests using structured tools and algorithms to help overcome cognitive biases that can lead to errors. When errors or near misses occur, organizations can capture data using a variety of methods and then develop non-punitive ways of learning from the errors.
“Clinical decision support interventions can also be helpful by identifying ordered tests that haven't been done or by flagging incidental findings that require follow-up," adds Horvath.
Opioid safety, second on this year's list, stretches across the healthcare continuum. “Opioids are a patient safety concern because of the seriousness of the side effects," says Stephanie Uses, PharmD, MJ, JD, patient safety analyst and consultant, ECRI Institute. "We recommend that clinicians carefully assess patients for opioid use disorder and set realistic expectations about pain."
ECRI Institute's 2018 list of patient safety concerns:
Opioid safety across the continuum of care
Care coordination within a setting
Incorporating health IT into patient safety programs
Management of behavioral health needs in acute care settings
All-hazards emergency preparedness
Device cleaning, disinfection, and sterilization
Patient engagement and health literacy
Leadership engagement in patient safety
"The list does not necessarily represent the issues that occur most frequently or are most severe. Most organizations already know what their high frequency, high-severity challenges are," says William Marella, MBA, MMI, executive director of Operations and Analytics of Patient Safety, Risk and Quality, ECRI Institute PSO. “Rather, this list identifies concerns that have appeared in our members' inquiries, their root cause analyses, and in the adverse events they submit to our Patient Safety Organization."
ECRI Institute PSO has received more than 2 million event reports and reviewed hundreds of root-cause analyses since 2009.
Source: ECRI Institute