The ECRI Institute, which recently released its third annual ranking of the Top 10 Patient Safety Concerns for Healthcare Organizations, reported that patient identification errors and inadequate management of behavioral health issues in non-behavioral health settings were its No. 2 and No. 3 issues for health care organizations.
When a health IT system is introduced, health care organizations should tailor it to their workflow, and vice versa, according to ECRI, which is based in Pennsylvania. But often, “after the implementation, people continue to do things the same way and really don’t adjust the health IT system or their workflow,” Robert Giannini, patient safety analyst at ECRI, said in a statement.
During its reviews of data, ECRI found patient identification problems were “not only frequent, but serious,” according to the group.
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ECRI reported that patient identification errors occur frequently.
Improper handling of behavioral health situations in non-behavioral-health settings can arise when hospital patients “behave aggressively due to psychiatric disorders, reactions to their treatment, or other reasons,” according to ECRI. Those situations, according to the group, can lead to injury or deaths of patients or staff.
In Connecticut, patient safety is a priority at hospitals, said Dr. Mary Cooper, vice president and chief quality officer at the Connecticut Hospital Association.
“All the hospitals across the state of Connecticut are taking an active interest in patient safety, and they have been for many years,” she said.
Connecticut is the only state, she said, in which all hospitals have adopted “high-reliability” standards. Roughly 50,000 health care workers statewide—at hospitals as well as ambulatory centers, behavioral health practices and other places—have been trained over the past three and a half years in how to better anticipate and prevent harm that may come to patients, Cooper said.
As a result, health care facilities have reduced the number patient infections, taken measures to reduce patient identification mistakes, and become more transparent in how they report adverse events, she said.
Lists like the ECRI’s, Cooper said, “are always a benefit to all of us,” since they give hospitals and other health care providers the chance to re-examine their efforts.
But despite ongoing patient safety efforts, more needs to be done, according to Lisa Freeman, executive director of the Fairfield-based Connecticut Center for Patient Safety.
“We still have a problem where I don’t know that all of health care is looking at itself and saying, ‘What can we doing differently?’” Freeman said.
Some health care organizations incorporate patient-focused care, when the emphasis should be on patient-centered care, she said. The first involves providing care to the patient, while the latter involves providing care with the patient, she added, and “the difference between the ‘for’ and the ‘with’ is significant.”
Changing to patient-centered care will take time and involve a culture shift in the health care industry, Freeman said. It also requires institutions to pay some upfront costs, which many are reluctant to do in a challenging economy, she added.
“Everybody would love to see patient harm reduced tremendously, but it’s not a simple answer,” she said. “We need to start looking at everything through the patient perspective. [But] it’s really not straightforward; there is no one solution.”
In the ECRI list, other patient safety-related issues rounding out the top 10 were, respectively: inadequate cleaning of flexible endoscopes, inadequate test result reporting and follow-up, inadequate monitoring for respiratory depression in patients prescribed opioids, medication errors related to pounds and kilograms, unintentionally retained objects despite correct counts, inadequate antimicrobial stewardship, and failure to embrace a culture of safety.
“We need to use these as a takeoff point, and hospitals and other caregiver institutions need to use these [types of] lists and self-reflect,” Freeman said. “These [incidents] are not just numbers and stats, these are people.”
To compile its list, ECRI analyzed its database of reported safety events and “seeks out expert judgment,” according to the nonprofit. The list is intended to help health care organizations identify priorities and create corrective action plans.
