Last time, our blog discussed how the Pennsylvania-based ECRI Institute recently released a new list outlining the top patient safety concerns of 2014.

The brainchild of a multidisciplinary team, the list was derived from careful examination of over 300,000 patient-safety events voluntarily reported to the ECRI Institute by over 1,200 U.S. hospitals.

To recap, “The Top 10 Patient Safety Concerns for Healthcare Organizations” outlined the following hazards:

1. Health information technology system failures
2. Poor patient care coordination/gaps in care levels
3. Reporting errors involving test results
4. Drug shortages
5. Failures to properly care for behavioral health patients 
6. Mislabeled specimens
7. Retained devices/fragments
8. Falls while toileting
9. Inadequate monitoring of patients taking opioids for respiratory distress
10. Inadequate sterilization/reprocessing of endoscopes and other surgical instruments

In today’s post, we will take a closer look at why the ECRI Institute is so concerned with these first two issues.

Health IT system failures

The ECRI Institute points out that thanks to financial incentives from the federal government, the use of electronic health record systems among hospitals and physicians tripled between 2009 and 2012.

While they acknowledge that these EHR systems can prove to be incredibly valuable if designed and implemented properly — providing health care providers with comprehensive and current patient information in just a few keystrokes — they also acknowledge just how much can go wrong if this not the case.

For instance, they point out how a poorly designed and implemented EHR system could result in everything from simple data entry errors to patient record mistakes. This, in turn, could cause more than just inconvenience and confusion, but actual patient harm as the missing or incorrect data could cause a medical professional to pursue the wrong course of treatment.

Poor patient care coordination

Another major concern for the ECRI Institute is breakdowns in patient care, meaning when there is a relative absence of communication between medical facilities, such that important — and otherwise life-saving information — is not shared.

As an example of all that can go wrong, the report discusses a scenario where a hospital patient was released with a discharge summary stating that she should undergo a magnetic resonance exam due to abnormal findings on a test. The discharge summary, however, was not forwarded to the primary care physician and the MRI was never performed. Consequently, the patient later died of what could have been a treatable condition.

Even looking at only two of these issues, it’s easy to see just how serious these patient safety concerns are and all the work that needs to be done. The hope is that hospitals and medical providers around the nation take the time to not only read the report, but implement its many worthwhile suggestions.

Source: ModernHealthcare.com, “Health IT issues, care-coordination worries top new ECRI safety list,” Sabriya Rice, April 22, 2014; ECRI Institute, “Health IT, care coordination, and drug shortages lead ECRI Institute’s 2014 List of Top 10 Patient Safety Concerns,” April 22, 2014