Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

April 2020

ECRI’s Top 10 Patient Safety Concerns for 2020

ECRI has published its annual “Top 10 Patient Safety Concerns” for 2020 (ECRI 2020). However, the download comes with a cover letter noting that the list was developed prior to the current coronavirus pandemic and that outbreak would clearly be one of the top patient safety concerns. Moreover, ECRI has established its COVID-19 (Coronavirus) Outbreak Preparedness Center that is loaded with very useful resources for everyone.

The Top 10 list for 2020:

Missed and Delayed Diagnoses
Maternal Health across the Continuum
Early Recognition of Behavioral Health Needs
Responding to and Learning from Device Problems
Device Cleaning, Disinfection, and Sterilization
Standardizing Safety across the System
Patient Matching in the Electronic Health Record
Antimicrobial Stewardship
Overrides of Automated Dispensing Cabinets
Fragmentation across Care Settings

Included in the document are links to resources for each of the 10 items. You’ll find those to be very helpful.

New to this year’s list is the focus on maternal health across the continuum. A year ago we did a column highlighting the frightening trend of increasing maternal mortality in the US (see our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spontlight”).

Another focus is early recognition of behavioral health needs. It states “Organizations can improve their recognition of and response to behavioral health needs by providing education, training and retraining, behavioral health assessment for patients, improving rapid response teams’ response times by conducting drills, and instituting a culture change that begins with the organization’s leadership.” It also focuses on the need to understand how to de-escalate situations dealing with aggressive, threatening, agitated, or violent behavior. Just last month we discussed how psychiatric and behavioral health problems have been recognized as a risk factor for preventable harm (see our March 2020 What's New in the Patient Safety World column “Risk Factor for Preventable Harm: Psychiatric Diagnosis”).

Item #4 Responding to and Learning from Device Problems reminds us that we often fail to learn valuable lessons following an event related to medical devices. It quotes the interesting statistic that patient harm from medical devices occurred in 84 of every 1,000 admissions in one hospital. It includes a downloadable poster for Device Incident Response that outlines the immediate action steps that should be undertaken when there is a device-related incident. Note that these elements have long been part of our own Serious Incident Response Checklist.

Item #9 Overrides of Automated Dispensing Cabinets is a problem we have highlighted in our January 1, 2019 Patient Safety Tip of the Week “More on Automated Dispensing Cabinet (ADC) Safety” and our multiple columns (listed below) related to a fatal incident involving a neuromuscular blocking agent (NMBA).

ECRI has done its usual great job of providing both emphasis on important patient safety issues and valuable resources to help you address them.

Our prior columns related to ADC’s (automated dispensing cabinets):

December 2007 “1000-fold Heparin Overdoses Back in the News Again”

August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency”

December 11, 2018 “Another NMBA Accident”

January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”

February 12, 2019 “From Tragedy to Travesty of Justice”

April 2019 “ISMP on Designing Effective Warnings”

June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”

References:

ECRI Institute. Top 10 Patient Safety Concerns 2020; ECRI Institute March 2020

https://www.ecri.org/landing-top-10-patient-safety-concerns-2020