Patient Safety Tip of the Week Archive

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What’s New in the Patient Safety World

May 2022

ECRI Top 10 Patient Safety Concerns for 2022

ECRI (ECRI 2022) has released it’s annual Top 10 Patient Safety Concerns for 2022:

1. Workforce shortages

2. Healthcare worker mental health problems linked to COVID-19

3. Bias and racism in addressing patient safety

4. Vaccine coverage gaps and errors

5. Cognitive biases and diagnostic error

6. Nonventilator healthcare-associated pneumonia

7. Human factors in operationalizing telehealth

8. International supply chain disruptions

9. Products subject to emergency use authorization

10. Telemetry monitoring

The COVID-19 pandemic has obviously weighed heavily on their choices.

We suggest you go to the ECRI site for full details on each of those concerns, so we’ll only comment on a few.

Workforce shortages should be near the top of everyone’s list. Burnout has taken its toll on an already aging workforce. Our January 2022 What's New in the Patient Safety World column “Another Striking Nurse Staffing Study” noted the impending shortage of nursing staff. But the anticipated shortages really apply to all categories of healthcare worker.

We have discussed several of the other concerns in columns over the years. Diagnostic error and the influence of cognitive biases on diagnostic error have long been on any lists of patient safety concerns. Our prior columns are listed below, including our most recent November 16, 2021 Patient Safety Tip of the Week “Cognitive Biases and Heuristics in the Delivery Room”.

Telemetry monitoring has also been a frequent topic. Unnecessary telemetry monitoring is a significant contributor to alarm fatigue and it is usually our number one target when we advise hospitals in reducing alarm fatigue. But there are other problems associated with telemetry monitoring. Our columns listed below have discussed telemetry units transposed on the wrong patients, battery-related issues, incidents during intrahospital transports, communication issues, and others. Our June 23, 2020 Patient Safety Tip of the Week “Telemetry Incidents” summarizes many of the issues encountered with telemetry.

See also our other columns related to COVID-19:

April 7, 2020 “Patient Safety Tidbits for the COVID-19 Pandemic”
May 5, 2020 “COVID-19 and the Dental Office”
May 12, 2020 “Lab Errors and COVID-19”
June 16, 2020 “Tracking Technologies”
November 2020 “Telemedicine Here to Stay But Use It Safely”
December 2020 “ISMP Warns of Vaccine Errors as We Gear Up for COVID-19 Vaccines”
January 26, 2021 “This Freezer Accident May Cost Lives”
September 2021 “Have You Added Pandemic Preparation to Your Hospital Disaster Plan?”
October 2021 “HAI’s Increase During COVID-19 Pandemic”
January 2022 “Some COVID-19 Practices May Outlast the Pandemic”
April 2022 “Another Benefit from the COVID-19 Pandemic?”

Some of our prior columns on cognitive biases and diagnostic error:

September 28, 2010 “Diagnostic Error”
November 29, 2011 “More on Diagnostic Error”
May 15, 2012 “Diagnostic Error Chapter 3”
May 29, 2008 “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work”
August 12, 2008 “Jerome Groopman’s “How Doctors Think”
August 10, 2010 “It’s Not Always About The Evidence”
January 24, 2012 “Patient Safety in Ambulatory Care”
October 9, 2012 “Call for Focus on Diagnostic Errors”
March 2013 “Diagnostic Error in Primary Care”
May 2013 “Scope and Consequences of Diagnostic Errors”
August 2013 “Clinical Intuition”
January 2014 “Trigger Tools to Prevent Diagnostic Delays”
January 14, 2014 “Diagnostic Error: Salient Distracting Features”
May 2014 “Frequency of Diagnostic Errors in Outpatients”
June 24, 2014 “Lessons from the General Motors Recall Analysis”
November 25, 2014 “Misdiagnosis Due to Lab Error”
April 21, 2015 “Slip and Capture Errors”
January 2020 “The Joint Commission on Closing the Loop”
April 20, 2021 “Taser “Slip and Capture Error” Again!”
November 16, 2021 “Cognitive Biases and Heuristics in the Delivery Room”

And our review of Malcolm Gladwell’s “Blink” in our Patient Safety Library

Some of our prior columns on the hazards associated with telemetry:

June 19, 2007 “Unintended Consequences of Technological Solutions”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
July 2011 “What's New in the Patient Safety World”
February 4, 2014 “But What If the Battery Runs Low?”
May 22, 2018 “Hazardous Intrahospital Transport”
June 23, 2020 “Telemetry Incidents”

References:

ECRI. Top 10 Patient Safety Concerns 2022. ECRI March 2022

https://www.ecri.org/top-10-patient-safety-concerns-2022

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