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What’s New in the Patient Safety World

February 2021

Top 10 Lists



This time of year is when all the “Top 10” lists on patient safety issues come out. Three big ones have come out from ISMP (Institute for Safe Medication Practices), ECRI Institute, and Becker’s Hospital Review.


ISMP’s “Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020” (ISMP 2021) has its list Top 10 Medication Errors and Hazards from 2020:

  1. Prescribing, dispensing, and administering extended-release (ER) opioids to opioid-naïve patients
  2. Not using smart infusion pumps with dose error-reduction systems (DERS) in perioperative settings
  3. Errors with oxytocin
  4. Hazards associated with positioning infusion pumps outside of COVID-19 patients’ rooms
  5. Errors with the COVID-19 vaccines
  6. Use of the retrospective, proxy “syringe pull-back” method of verification during pharmacy sterile compounding
  7. Combining or manipulating commercially available sterile products outside the pharmacy
  8. Medication loss in the tubing when administering small-volume infusions via a primary administration set
  9. Wrong route (intraspinal injection) errors with tranexamic acid
  10. Use of error-prone abbreviations, symbols, or dose designations


ECRI Institute’s “Top 10 Health Technology Hazards for 2021” (ECRI 2021)

(ECRI 2021):

  1. Complexity of Managing Medical Devices with COVID-19 Emergency Use Authorization
  2. Fatal Medication Errors Can Result When Drug Entry Fields Populate after Only a Few Letters
  3. Rapid Adoption of Telehealth Technologies Can Leave Patients and Data at Risk
  4. Imported N95-Style Masks May Fail to Protect Healthcare Workers from Infectious Respiratory Diseases
  5. Relying on Consumer-Grade Products Can Lead to Inappropriate Healthcare Decisions
  6. Hasty Deployment of UV Disinfection Devices Can Reduce Effectiveness and Increase Exposure Risks
  7. Vulnerabilities in Third-Party Software Components Present Cybersecurity Challenges
  8. Artificial Intelligence Applications for Diagnostic Imaging May Misrepresent Certain Patient Populations
  9. Remote Operation of Medical Devices Designed for Bedside Use Introduces Insidious Risks
  10. Insufficient Quality Assurance of 3D-Printed Patient-Specific Medical Devices May Harm Patients


Becker’s 10 top patient safety issues for 2021 (Carbajal 2021):

  1. COVID-19
  2. Healthcare staffing shortages
  3. Missed and delayed diagnoses
  4. Drug and medical supply shortages
  5. Low vaccination coverage and disease resurgence
  6. Clinician burnout
  7. Health equity
  8. Healthcare-associated infections
  9. Surgical mistakes
  10. Standardizing safety efforts



Even though the themes of these lists are slightly different for each organization, you can see there is still considerable overlap and issues related to COVID-19, directly or indirectly, dominate the lists. We refer you to the original articles for details of each item on the respective lists.






ISMP (Institute for Safe Medication Practices). Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020. ISMP Medication Safety Alert! Acute Care Edition 2011; 26(2): January 27, 2021



ECRI Institute. Top 10 Health Technology Hazards for 2021. ECRI Institute 2021; January 2021



Carbajal E, Masson G, Bean M. Becker’s 10 top patient safety issues for 2021; Becker’s Hospital Review 2021;






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