2015 Patient Safety Top10

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Transcript of 2015 Patient Safety Top10

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 Top 10Patient Safety

Concerns forHealthcare

Organizations

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Publisher: ECRI Institute

EXECUTIVE STAFF

Jeffrey C. Lerner, Ph.D.Presiden and Chief Execuive Officer

Anthony J. Montagnolo, M.S.Execuive Vice Presiden andChief Operaing Officer

Ronni P. Solomon,  J.D.Execuive Vice Presiden andGeneral Counsel

 Vivian H. Coates, M.B.A.Vice Presiden, Informaion Servicesand Technology Assessmen

Michael Argentieri, M.S., BMEVice Presiden, Marke Developmen

Mark E. Bruley, 

CCEVice Presiden, Acciden andForensic Invesigaion

G. Daniel Downing, M.B.A.Vice Presiden, Finance

James P. Keller, Jr., M.S.Vice Presiden, Healh TechnologyEvaluaion and Safey

Jennifer L. Myers 

Vice Presiden, SELECT HealhTechnology Services

Thomas E. Skorup, M.B.A., FACHEVice Presiden, Applied Soluions

David W. Watson, Ph.D.

Vice Presiden, Operaions,ECRI Insiue Europe

Jin Lor, MIE (Aus)Regional Direcor, Souheas Asia

MISSION STATEMENT

ECRI Insiue is an independennonprofi organizaion whose missionis o benefi paien care by promoinghe highes sandards of safey, qualiy,and cos-effeciveness in healhcare.We accomplish his hrough ourresearch, publishing, educaion, andconsulaion.

Our goal is o be he world’s mosrused, independen, organizaionproviding healhcare informaion,research, publishing, educaion andconsulaion o organizaions andindividuals in healhcare.

 

ECRI Insiue, 5200 Buler PikePlymouh Meeing, PA 19462-1298, USATel + 1 (610) 825-6000

Download additional copies of this

report and access more resources at

www.ecri.org/PatientSafetyTop10.

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©2015 ECRI Institute.APRIL 2015 3

Top 10 Patient Safety Concerns for Healthcare Organizations

Introduction

NOT JUST A TOP 10 LIST

Wih his repor, ECRI Insiue is releasing is op 10 lis of paien safey concerns for 2015. This is he second year we

have compiled he lis, which is parly based on our review of paien safey even repors, research requess, and roo-

cause analyses submited o ECRI Insiue PSO, one of he firs paien safey organizaions (PSOs) o be federally cerified

under he provisions of he Paien Safey and Qualiy Improvemen Ac (PSQIA).

PSQIA gives healhcare organizaions a unique opporuniy o volunarily share heir safey surveillance daa in a

proeced environmen so PSOs can aggregae and analyze he daa. The law also charges PSOs wih he responsibiliy

o share he findings and lessons learned. The release of our op 10 lis of paien safey concerns is in keeping wih haresponsibiliy.

ECRI Insiue’s Top 10 Paien Safey Concerns for Healhcare Organizaions is more han jus a lis; i’s a reminder ha,

despie he atenion given o paien safey over he las 15 years or so, we can do beter. Since we began collecing paien

safey evens in 2009 as a PSO, we have received nearly 500,000 even repors. Each even ofen describes a sysems-relaed

 breakdown, or a near failure, in he care process of he paiens our members are commited o serving. Some of he evens

describe serious, prevenable paien injuries or deahs.

Behind each even here’s a sory abou paiens and heir loved ones who pu hemselves in he hands of heir provid-

ers expecing qualiy care and services. And here’s a separae sory abou he providers whose lives and careers are orn

apar when paiens are harmed because fauly sysems and processes make problems more likely o occur.

Our paien safey analys Sheila Rossi, who shares her own encouner wih a medicaion error in his year’s repor,

reminds us of he sories behind hese evens and he moivaion for our op 10 lis. “When we say ‘he paien’ in healh-care, i someimes becomes impersonal,” Rossi says, urging everyone o pu hemselves in paiens’ shoes and o ask,

“How do I preven his from happening o me?”

Healhcare providers, regardless of wha seting hey pracice in, can sar wih our op 10 lis of paien safey concerns

and use i o guide heir own discussions abou paien safey and improvemen iniiaives.

We will coninue o publish our op 10 lis annually because we are commited o paien safey and o helping you o

deliver he safes care for all of us, your paiens.

Sincerely,

William M. Marella, MBA

Execuive Direcor, Operaions and Analyics

ECRI Insiue’s Paien Safey, Risk, and Qualiy Group

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©2015 ECRI Institute. APRIL 20154

Top 10 Patient Safety Concerns for Healthcare Organizations

Top 10 Patient Safety Concerns

for Healthcare Organizations: 2015

ECRI Insiue has released is newes lis of he op 10 paien safey concerns confroning

healhcare organizaions. The lis serves as a “caalys for discussion” among healhcare lead-

ers abou he op paien safey issues faced by heir organizaions, says Caherine Pusey,

RN, MBA, manager, clinical analyss a ECRI Insiue PSO.

ECRI Insiue’s Top 10 Paien Safey Concerns for Healhcare Organizaions for 2015 is compiled

 by ECRI Insiue PSO, one of he firs paien safey organizaions (PSOs) o be federally cerified.

“The lis is based on wha we see hroughou he year among he paien safey even repors,

research requess, and roo-cause analyses submited o ECRI Insiue PSO,” says Pusey.

Under he Paien Safey and Qualiy Improvemen Ac, healhcare organizaions canvolunarily submi paien safey repors o PSOs in a proeced environmen for PSOs o

aggregae, analyze, and share findings and lessons learned. ECRI Insiue PSO has been

collecing paien safey daa since 2009 and, by he end of 2014, had received nearly 500,000

even repors.

The lis also draws upon ECRI Insiue saff experise,

including he knowledge gained invesigaing incidens,

observing and assessing hospial pracices, and review-

ing healh-echnology-relaed problem repors submited

o ECRI Insiue’s volunary medical device problem

reporing program. In fac, four of he paien safey con-

cerns idenified for he op 10 lis also rank among ECRIInsiue’s op healh echnology hazards for 2015. Refer o

“ECRI Insiue’s Top 10 Liss” for more informaion on he

healh echnology hazard lis, which is compiled by ECRI

Insiue’s Healh Devices Group.

“Mos organizaions have heir own op 10 lis. They

should review our lis of paien safey concerns o idenify

issues ha should be on heirs,” says Pusey. “We’re no

saying ha every organizaion mus address all 10 opics,

 bu hey should deermine where here are similariies and

variaions.”

Using ECRI Insiue’s op 10 lis proacively o improvequaliy of care and paien safey is also in keeping wih

he provisions of he Join Commission’s recenly released

paien safey sysems chaper for is 2015 accredia-

ion manual. The chaper describes he imporance and

srucure of an inegraed approach o paien safey for

healhcare organizaions.

1 Alarm hazards: inadequate alarm configurationpolicies and practices*

2Data integrity: incorrect or missing data in EHRsand other health IT systems

3 Managing patient violence

4Mix-up of IV lines leading tomisadministration of drugs and solutions*

5Care coordination events related to medicationreconciliation

6Failure to conduct independent double checksindependently*

7 Opioid-related events

8Inadequate reprocessing of endoscopes andsurgical instruments

9Inadequate patient handoffs related to patienttransport*

10Medication errors related to pounds andkilograms*

ECRI Institute’s Top 10 Patient Safety Concerns for 2015

*New to the 2015 list.

        M        S        1        5        1        3        8

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©2015 ECRI Institute.APRIL 2015 5

Top 10 Patient Safety Concerns for Healthcare Organizations

Half of he iems on he op 10 lis are new for 2015; he oher half are recurring or varia-

ions of concerns from 2014 when ECRI Insiue firs released is op 10 lis of paien safey

concerns. Refer o “ECRI Insiue’s Top 10 Paien Safey Concerns for 2015” for he full lis.

Iems from he 2014 lis ha do no appear on his year’s lis, such as mislabeled

laboraory specimens and paien falls while oileing, sill remain a concern, says Pusey.

“Bu oher opics have risen o a higher level of atenion.”

APPLICABILITY TO MULTIPLE SETTINGS 

Many of he opics on ECRI Insiue’s lis of op 10 paien

safey concerns exend o muliple healhcare setings and

highligh he relevance of hese issues o he coninuum

of care spanning physician pracices and oher oupaien

medical setings, acue care hospials, and aging services

providers in posacue care environmens, nursing homes,

and hospice care.

“While some of hese hazards are mos applicable

o acue care, several are also relevan in ambulaory

setings, and some—especially hose relaed o medicaions

and care coordinaion—span he coninuum of care,” saysWilliam M. Marella, MBA, execuive direcor, operaions

and analyics for ECRI Insiue’s Paien Safey, Risk, and

Qualiy group.

Because he opics on ECRI Insiue’s lis of paien

safey concerns are largely based on repors submited

 by hospials, hese issues, while imporan o muliple

healhcare setings, may no always rank among he op

10 concerns for nonhospial setings, such as physician

pracices and aging services providers. For example, appro-

priae managemen of alarms is imporan in long-erm

care setings such as nursing homes where alarms are used

o deec residen wandering and elopemen, falls, and

oher risks, says Vicor Lane Rose, NHA, MBA, CPASRM,

operaions manager of ECRI Insiue’s Aging Services Risk

Managemen program wihin is Paien Safey, Risk, and

Qualiy group. The opic, however, may no rank as aging

services providers’ number one concern, he adds, because

oher issues, such as skin managemen, appropriae saffing

and scheduling, and falls managemen, are ypically

among he highes prioriies for he aging services secor.

Hospital

 AgingServices

        M        S        1        5        1        3        9

 AmbulatoryCare

Many of the Top 10 Safety Events Span

Multiple Healthcare Settings

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Top 10 Patient Safety Concerns for Healthcare Organizations

ECRI Institute’s Top 10 Lists

ECRI Insiue’s op 10 liss of paien safey concerns and healh echnology hazards highligh four overlapping issues ha deservehe atenion of healhcare organizaions. Togeher, hey reflec a unied effor by ECRI Insiue o promoe paien safey in healh-care organizaions.

ECRI Insiue’s Top 10 Health Technology Hazards , released every fall, focuses on echnology, whereas ECRI Insiue’s Top 10Patient Safety Concerns for Healthcare Organizations addresses broader paien safey issues. Like he lis of paien safey concerns, heop 10 lis of healh echnology hazards reflecs ECRI Insiue’s healhcare safey experise. The lis is compiled based on he saff’sexperience invesigaing device-relaed incidens, evaluaing medical devices in ECRI Insiue’s esing laboraory, and reviewingrepors from ECRI Insiue’s and oher organizaions’ daabases for medical device problems and paien safey evens.

ECRI Insiue has published is lis of healh echnology hazards for eigh years and is lis of paien safey concerns for woyears. Boh liss are published annually.

Despie he differen focuses of he wo liss, Caherine Pusey, RN, MBA, manager, clinical analyss a ECRI Insiue PSO, issruck ha wo differen eams idenified four overlapping areas as prioriies for healhcare organizaions in 2015. “Separaely,we are idenifying some of he same issues.” The four overlapping concerns are as follows:

1. Alarm hazards from inadequae alarm configuraion policies and pracices2. Daa inegriy failures from incorrec or missing daa in EHRs and oher healh IT sysems

3. IV line mix-ups leading o misadminisraion of drugs and soluions

4. Inadequae reprocessing of endoscopes and surgical insrumens

In fac, hese four echnology-relaed opics are he op four iems idenified in ECRI Insiue’s Top 10 Health TechnologyHazards for 2015. The overlap of hese four prioriy opics “shows he significance of healhcare echnology as i impacs paiensafey overall,” says James P. Keller, MS, vice presiden, healh echnology evaluaion and safey, ECRI Insiue. “A big reasonwhy echnology shows prominenly on he op 10 lis of paien safey concerns is he growing complexiy of echnology and heincreased reliance on echnology in delivering healhcare,” he says, lising areas such as healh IT and alarm hazards.

The 2015 repor of healh echnology hazards also has some broader opics ha span muliple echnologies. One was insuf-ficien cybersecuriy proecions for medical devices and sysems. “Despie litle evidence o dae of direc harm o paiens,cybersecuriy is neverheless a poenial hrea ha healhcare faciliies mus begin addressing,” says Rob Schluh, senior projec

officer a ECRI Insiue and he lead projec manager for ECRI Insiue’s Top 10 Health Technology Hazards for 2015 projec. “Thevulnerabiliy of medical devices o malware ha could affec device funcionaliy or he inegriy of paien daa is of paricularconcern.” ECRI Insiue predics ha cybersecuriy is a paien safey consideraion ha will require increased atenion in hecoming years.

Anoher broad opic on he 2015 op echnology hazards lis was deficien medical device recall and safey-aler managemenprograms. “We see healhcare organizaions wih aniquaed recall managemen programs,” says Schluh. “One key concern wehave is ha he capabiliies of some hospials’ programs may no be keeping pace wih he growh over he pas decade in henumber of recalls and oher alers ha are issued.”

ECRI Insiue also publishes an annual wach lis of he op 10 echnology and infrasrucure issues ha a hospial C-suieshould carefully examine. The lis draws upon ECRI Insiue’s decades of experience evaluaing he safey, effeciveness, and cos-effeciveness of healh echnologies.

“C-suie leaders need a concise way of seeing where new and emerging healh echnologies fi, if a all, in heir healh sys-ems,” says Diane Roberson, direcor, healh echnology assessmen, ECRI Insiue.

Topics on he 2015 C-suie lis include he following:

 Z Disinfecion robos

 Z Three-dimensional priners

 Z Google Glass

 Z Posdischarge clinics

All hree repors are publicly available from ECRI Insiue’s websie. Top 10 Health Technology Hazards for 2015 is publiclyavailable a htps://www.ecri.org/Pages/2015-Hazards.aspx. The 2015 Top 10 Hospital C-Suite Watch List is freely available ahtps://www.ecri.org/Pages/ECRI-Insiue-2015-Top-10-Hospial-C-Suie-Wach-Lis.aspx.

Top 10 Patient Safety Concerns for Healthcare Organizations

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Top 10 Patient Safety Concerns for Healthcare Organizations

ECRI Insiue recommends ha healhcare organizaions

use is op 10 lis of paien safey concerns as a saring

poin for heir paien safey discussions and for se-

ing heir paien safey prioriies. Use he lis o idenify

wheher he organizaion has experienced paien safey

 breakdowns in similar areas and wheher he concerns

should be argeed for improvemen. For areas seleced

for improvemen, organizaions can creae risk miiga-

ion sraegies based on he recommendaions providedwih he op 10 lis for each area of concern. Addiional

ECRI Insiue resources, some freely available on ECRI

Insiue’s websie, are highlighed hroughou he repor.

“Our hope is ha healhcare providers use his lis o

reflec on which of hese hazards exis in heir care setings

and on wheher hey have sysems in place o preven or

minimize harm from hose ha are relevan in heir se-

ings,” says Marella.

Rose recommends ha faciliies across he healhcare

specrum use he lis o “undersand he risks ha do exis

a your organizaion, o quanify hem, and o find ouwhere hey’re happening so he organizaion can idenify

pracices o miigae he risks.”

Given ha paien safey improvemens can ofen

require an invesmen in saff ime and he organizaion’s

resources, Pusey recommends ha organizaions presen

he lis o heir senior leaders and members of heir govern

ing boards o gain heir atenion and suppor.

How the List

Was Compiled

To compile is lis of paien safey concerns, ECRI Insiue

PSO reviewed is daabase of paien safey evens, roo-

cause analyses, and cusom research requess submited

hroughou he year by healhcare organizaions and is

parner PSOs, as well as sough guidance from is eam of

expers.

“Our op 10 lis isn’ generaed from a complicaed

algorihm or formula. I’s very much a consensus process

ha atemps o disill he judgmen of ECRI Insiue’spaien safey expers, our advisors, and our members,”

says Marella. “Topics are nominaed based on our analysis

of safey evens repored o ECRI Insiue and our parner

PSOs as well as wha’s happening in he broader paien

safey communiy.”

The final lis reflecs he inpu of ECRI Insiue PSO’s

eam of analyss and oher ECRI Insiue saff, as well as

members of ECRI Insiue PSO’s advisory council.

How to

Use the List

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Top 10 Patient Safety Concerns for Healthcare Organizations

1. Alarm Hazards: Inadequate Alarm

Confguration Policies and Practices

Topping he lis of paien safey concerns is alarm hazards from inadequae alarm configura-

ion policies and pracices, a opic which also ranks as ECRI Insiue’s op healh echnology

hazard for 2015.

Since ECRI Insiue began publishing is lis of op healh echnology hazards in 2007,

“alarm hazards have been a or near he op of he lis,” says Rob Schluh, senior projec offi-

cer a ECRI Insiue and he lead projec manager for he Top 10 Healh Technology Hazards for 2015 projec. The need o address alarm hazards is paricularly imporan wih he Join

Commission’s ongoing Naional Paien Safey Goal for healhcare organizaions o improve

he safey of clinical alarm sysems.

In recen years, much of he lieraure relaed o alarm hazards has focused on alarm

faigue—a condiion ha can lead o alarms missed by providers who are overwhelmed by,

disraced by, or desensiized o he muliple alarms ha acivae.

In is 2015 lis, ECRI Insiue encourages healhcare insiuions o look beyond alarm

faigue. “In addiion o missed alarms ha can resul from excessive alarm acivaions, hospi-

als also have o be concerned abou alarms ha don’ acivae when a paien is in disress,”

says Schluh. “In our experience, alarm-relaed adverse evens—wheher hey resul from

missed alarms or from unrecognized alarm condiions—ofen can be raced o alarm sysemsha were no configured appropriaely.”

To mee he Join Commission’s Naional Paien Safey Goal on clinical alarm safey,

organizaions accredied by he group mus, as of 2016, esablish policies and procedures

o manage alarm signals idenified by he organizaion as essenial for paien safey. ECRI

Insiue recommends ha organizaions examine heir alarm configuraion policies and pro-

cedures o address he full range of facors ha can lead o alarm hazards.

“Our acciden invesigaions have found ha hospials have eiher no had consisen or no

had any pracices o deermine how alarms are se by care area or by paien ype,” says James

P. Keller, MS, vice presiden, healh echnology evaluaion and safey, ECRI Insiue. For

example, “i doesn’ make sense o use he same defaul alarm setings in pediaric inensive

care as in adul inensive care,” he explains, ye ECRI Insiue has found ha many hospials

do no have a policy o adjus he alarm defaul setings by care area. Similarly, hospial

policies ofen fail o specify when and who can make adjusmens o he defaul alarm setings,

says Keller.

In addiion o he recommendaions for addressing alarm hazards conained in he Top 10

Healh Technology Hazards for 2015 , ECRI Insiue has compiled is Alarm Safey Handbook and

 Alarm Safey Workbook o help organizaions undersand he breadh of alarm hazards, idenify

alarm safey vulnerabiliies, and develop an effecive program for managing clinical alarms o

improve paien safey. The maerials are provided as a membership benefi for cerain ECRI

Insiue programs and are available o ohers for purchase. See “ECRI Insiue Resources” for

more informaion.

* Some ECRI Insiue resourcesare publicly available. To obainoher ECRI Insiue repors,conac us by elephone a (610)

825-6000, ex. 5891, or by e-maila [email protected].

ECRI INSTITUTE

RESOURCES

HRC 

 Z Clinical Alarms

Other Memberships

and Sources*

 Z The Alarm SafetyHandbook: Strategies,Tools, and Guidance and accompanyingworkbook.

 Z Alarm SafeyResource Cener 

Z Inerfacing Monior-ing Sysems wihVenilaors: How Well 

Do They Communi-cae Alarms? (HealthDevices)

 Z Physiologic Monior-ing Sysems: Our

 Judgmens on EighSysems (HealthDevices)

 Z Top 10 Health Technol-ogy Hazards for 2015

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Top 10 Patient Safety Concerns for Healthcare Organizations

Healh informaion echnology (IT)–relaed issues have been a recurring heme on ECRI Insiue’s

op 10 liss, appearing on he op 10 healh echnology hazards lis for he las six years and on

he op 10 lis of paien safey concerns since is sar in 2014. For he wo mos recen years, boh

liss have idenified daa inegriy errors as a resul of incorrec or missing daa in elecronic healh

records (EHRs) and oher healh IT sysems.

ECRI Insiue recognizes ha healh IT offers numerous poenial benefis, such as suppor-ing clinical decision making, enhancing provider communicaion, providing access o paien

daa in a secure environmen, engaging paiens, and reducing medical errors. Bu he echnology

can creae new safey risks if i is no designed appropriaely, implemened carefully, and used

houghfully.

In fac, in 2014, ECRI Insiue convened he Parnership for Healh IT Paien Safey , a muli-

sakeholder collaboraive esablished o proacively idenify and address healh IT paien safey

risks in a nonpuniive environmen.

 “Wih he inroducion of any new echnology, we need o idenify and respond o novel prob-

lems i presens as well as old problems ha he new echnology doesn’ eliminae,” says Marella.

Daa inegriy issues “exised wih paper medical records as well, bu now as EHRs become more

ineroperable, incorrec informaion is more readily available, more easily shared, and harder oeliminae,” he says. “In order o ge a reurn on he invesmen we’ve made in EHRs and clinical

decision suppor, we now need o ackle he more mundane problem of making sure he daa in he

EHR is accurae.”

 “We’ve seen he rapid growh of healh IT sysems, paricularly in he hospial seting,” says

Keller. “Organizaions need o have beter esing of he sysems and checks and balances [afer

implemenaion] o make sure failure poins for missing daa or incorrec daa enries are ideni-

fied and addressed.” As an example, consider he following even repored o ECRI Insiue PSO

and is parner PSOs involving wo separae healh IT sysems—an EHR sysem and a dieary

managemen program:

The paien’s peanu allergy was lised in he EHR bu he informaion did no cross over o he dieary

deparmen’s sysem. The paien quesioned wheher he food allergy informaion had been received by hedieary deparmen afer receiving a food ray ha was no idenified as free of peanu producs.

The near miss highlighed he need for a sofware fix o ensure ha imporan paien daa from

he EHR is ransferred o he organizaion’s dieary IT sysem for paien menu managemen.

2. Data Integrity: Incorrect or

Missing Data in EHRs and OtherHealth IT Systems

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Top 10 Patient Safety Concerns for Healthcare Organizations

Examples of daa inegriy failures, as lised in he Top 10 Healh Technology Hazards for

2015 repor, include he following:

 X Appearance of one paien’s daa in anoher paien’s record

 X Missing daa or delayed daa delivery

 X Clock synchronizaion errors beween medical devices and sysems

 X Defaul values being used by misake, or fields being prepopulaed wih

erroneous daa

 X Inconsisencies in paien informaion when boh paper and elecronic records

are used

 X Oudaed informaion being copied and pased ino a new repor

To correc hese problems, organizaions mus idenify daa inegriy failures as hey

occur in order o apply fixes o preven similar problems from recurring. To do so, hey mus

empower fronline workers and healh IT sysem users o repor all ypes of healh IT-relaed

incidens, including hose ha do no cause any harm as well as near-miss incidens, and

circumsances ha precede an acual even and are caugh before anyhing can happen.

Through is problem and even reporing programs, ECRI Insiue has found ha healh-care saff do no always recognize healh IT’s conribuion o an even. For example, only

afer analysis of an inciden in which a pharmacis placed a medicaion order in he wrong

paien’s record was i recognized ha he error was faciliaed by a medicaion managemen

sysem ha allowed users o have muliple paien records open a he same ime. Reporing

he even as jus a medicaion error overlooks oher conribuing facors, such as he healh

IT sysem’s configuraion o permi muliple paien records o be open on a user’s screen.

“When reporing an adverse even or near miss, saff should consider wheher

some funcion or feaure of a healh IT sysem could have conribued o he problem,” says

Schluh.

Some even reporing programs give reporers he abiliy o idenify he repor as a healh

IT-relaed issue. For example, he Agency for Healhcare Research and Qualiy’s mos recenversion of he Common Formas (version 1.2) includes an even repor for healh IT evens

and unsafe condiions. The Common Formas are used by PSOs and heir paricipaing pro-

viders for even reporing and allow daa aggregaion in a sysemaic manner.

ECRI INSTITUTE

RESOURCES

HRC 

 Z Elecronic Healh

Records

Other Memberships

and Sources

 Z ECRI Institute PSODeep Dive: HealthInformation Technology

 Z Healh IT ParnershipProceedings: Parner-ing for Success

 Z How o Connecwih he Righ EMRInegraion Vendor (Health Devices)

 Z Making Connec-ions: InegraingMedical Devices wihElecronic Medi-cal Records (HealthDevices)

 Z Paien Safey aInersecion of Medi-cal and InformaionTechnology (PSONavigator)

 Z Top 10 Health Technol-ogy Hazards for 2015

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Every day, U.S. hospials deal wih violen paien incidens and hreaening behaviors ha

affec he safey and well-being of saff, paiens, and visiors. According o curren lieraure

on he opic, violence is occurring in all care setings, even in oncology and maerniy unis,

and no jus in he emergency deparmen (ED).

Clinical saff in acue care unis ypically lack raining in behavioral healh and may dis-

miss or poorly handle behavioral cues ha signal imminen violence, says Ruh Ison, MDiv,STM, paien safey analys/consulan a ECRI Insiue PSO. Ison noes ha repors submi-

ed o ECRI Insiue PSO and is parner PSOs show ha docors, nurses, ancillary saff, and

even securiy officers working in emergency and acue care setings are grealy challenged

in managing paiens who become violen or hreaen violence. In 2014, failure o adequaely

manage hreaening or violen behavior of paiens in acue care setings was among ECRI

Insiue’s op 10 paien safey concerns.

The range and impac of paien violence across he hospial is no limied o incidens

ha make he headlines. Clinical saff may feel abandoned and lef wihou he resources o

do heir jobs safely, given he frequency wih which hey mus manage violen behavior in

paiens—a leas 15 incidens a day, according o one PSO member hospial.

The firs hing ha hospial leadership mus do is acknowledge ha violence is occurringwihin he faciliy’s walls, says Judy Gushue, RN, BS, MJ, CEN, CPHQ, paien safey analys,

ECRI Insiue PSO. When healhcare workers perceive assauls and hreas as a workplace

hazard ha mus be oleraed, hey underrepor—resuling in lack of awareness and inac-

ion by hospial leadership. “Lack of psychiaric services and inervenions pus pressure on

nurses and oher fronline saff o be rained in violence de-escalaion echniques,” she poins

ou.

Ison believes ha raining saff in de-escalaion sraegies is a smar invesmen ha can

improve paien and worker safey on many levels, reducing coercion and empowering saff

o engage, raher han avoid, paiens wih agiaion or hreaening behavior while promo-

ing safe condiions. The effor may prove o be more cos-effecive han use of unrained

“siters,” who have been menioned in PSO even repors as he arges of atacks by paiens,

Ison says. The siter’s presence or behavior may be perceived by he paien as provoca-

ive, as he siter is placed in he posiion of prevening he paien from engaging in cerain

unsafe behaviors, she noes. Unrained siters may no be sensiive o he paien’s clinical

siuaion, may no fully undersand he recommended safey precauions, or may argue wih

he paien. Oher siter behaviors (e.g., exing, chating, playing games on a smarphone)

migh resul in siter inatenion or even provoke a violen response from he paien.

3. Managing Patient Violence

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Top 10 Patient Safety Concerns for Healthcare Organizations

Gushue adds ha in addiion o requiring reporing and providing saff raining in de-

escalaion sraegies and skills, he hospial should have a faciliy-wide safey plan ha

considers all levels of risk, from he single acue episode of hreaening behavior o an acive

shooer siuaion anywhere in he faciliy or on campus. “Know he risks posed by your

paien populaion—local police saisics may help idenify areas of risk or peak periods

when risk may be greaer.” The program should address physical securiy and response(e.g., use of hidden alarms, cameras, elecronic saff locaor services, increased sraegic secu-

riy presence, limiing sies of enrance and egress a nigh), implemening and monioring

compliance wih policies and procedures for inspecing belongings of visiors and paiens

for weapons, reconfiguring ED waiing areas, invoking emergency legal processes for com-

mimen or reamen (when appropriae), and esablishing a rained rapid response eam o

assess poenial violen behavior and inervene when summoned.

Ison agrees: he acue sympoms ha demonsrae a paien’s behavioral or medical

inabiliy o cooperae wih care inervenions should no be misinerpreed by healhcare

workers as unwillingness; however, “aggressive or agiaed behavior signals a high-risk,

high-acuiy siuaion ha needs immediae clinical atenion comparable o a sroke, cardiac,

or respiraory even.” Ison has idenified he following paien facors from ECRI Insiue

PSO even repors involving violen paien behavior: acue subsance abuse or addicion,acue wihdrawal, drug-seeking behavior, psychosis, possurgical saus, and various medi-

cal and menal healh comorbidiies (e.g., neurologic disorders, infecions, delirium, adverse

prescripion drug reacions, developmenal disabiliies) combined wih behavioral healh

sympoms (e.g., paranoia, moor agiaion, emoional volailiy) and social dislocaion.

Clinical managemen sraegies can include sanding orders and medicaion order ses

ha can be acivaed immediaely by he saff on duy, as well as securiy measures. And

while acuely agiaed or hreaening, violen paiens should never be handed off, as hese

are emergency siuaions. Subsequen handoff communicaion of he paien’s medical saus

should include idenificaion of acue socioemoional or behavioral healh issues ha are

adversely affecing he paien, Ison says. These migh be addressed by social workers or

 behavioral healh saff.Diminishing he risks involved wih paien violence sars wih acceping is realiy

across healhcare setings, Gushue says. The experise of leadership, managemen, and

clinical saff a all levels is needed o develop a comprehensive response ha mees hese

vulnerable paiens’ medical needs and keeps all healhcare saff safe in he process.

ECRI INSTITUTE

RESOURCES

HRC 

 Z Paien Violence Z Workplace Violence

Prevenion Plan 

Z Violence Risk Assess-men Tool for HomeCare

Other Memberships

and Sources

 Z Residen Aggres-sion and Violence (Continuing Care Risk

 Management)

 Z Residen Aggression/Violence AssessmenTool (Continuing CareRisk Management)

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4. Mix-Up of IV Lines Leading to

Misadministration of Drugs andSolutions

Inravenous (IV) line mix-ups can lead o medicaion errors, resuling in wrong-drug,

wrong-rae, wrong-dose, or wrong-sie infusions, some wih serious consequences. Paiens,

paricularly hose in criical care setings, can have muliple IV infusions, increasing he risk

of connecing he line o he wrong infusion pump, wrong fluid conainer, or wrong adminis-

raion roue.

Paiens may have oher inerfering facors, such as leads and cables for physiologic moni-ors, increasing he risk of misakes wih IV line mix-ups, says Keller. Someimes described

as “spagheti syndrome” or he angle of ubes, caheers, and cables ha engulf paiens, he

muliple lines “make i harder o rack he source of an IV line as i leads from he paien’s

inserion sie o he original source,” he says.

In he following even repored o ECRI Insiue PSO and is parner PSOs, an older

paien received oo much heparin because he IV lines for heparin and saline were

misconneced:

The ED paien was suspeced of having a hear atack and was sared on a high-risk proocol for

IV heparin. Afer he paien was ransferred o he uni, he nurse noiced ha he heparin bag was

almos empy. The nurse checked he pump and saw ha i was running a he faser rae inended for

he saline soluion. The ubing lines were mixed up, and he heparin ran for four hours a he faserrae, resuling in he paien receiving seven imes as many unis of heparin as inended. The paien

was reaed for a heparin overdose and ransferred o he criical care uni.

Alhough he risk of IV line mix-ups is pronounced in he criical care seting, he risk also

exiss in oher acue care setings, as he above even illusraes, and in nonhospial setings,

such as a nursing home, where residens may require, for example, boh an IV anibioic and

pain medicaion. Alhough paiens in hese setings may have fewer lines, misakes can sill

occur, paricularly if he provider does no have he same advanced raining as a criical care

nurse o ensure safey, says Keller.

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Top 10 Patient Safety Concerns for Healthcare Organizations

Among ECRI Insiue’s recommendaions o preven IV infusion-line confusion are he

following:

 X Trace all lines back o heir origin before making connecions. Doing so verifies ha

he correc lines will be joined. Lines should be rechecked upon he paien’s arrival

in a new seting or service and a shif changes as par of he handoff process.

X Develop a policy of posiioning differen lines on differen sides of he paien. Con-sisenly puting lines in he same place migh make i easier for clinicians o correcly

idenify hem and connec hem appropriaely.

 X Label each infusion line wih he name of he drug or soluion being infused.

 X Do no force connecions. If a connecion is difficul o make—ha is, if i requires a

lo of effor—chances are i should no be made.

Separaely, misconnecions can also occur when ubing from one delivery sysem is

misconneced o a sysem inended for a differen purpose (e.g., an eneral feeding pump

 being conneced o an IV line). New connecor sandards are being developed o reduce his

risk; however, he sandards will no preven all line misconnecions. Once he new design

sandards for connecors are fully in place, IV lines will coninue o use he same ype of con-

necor, making i possible o sill have IV infusion mix-ups.

ECRI Insiue recommends using posers o remind saff abou sraegies o preven ub-

ing misconnecions. For example, ips for clinical saff are summarized in a poser developed

 by ECRI Insiue summarizing is TRACER™ program o preven ubing misconnecions.

Informaion for obaining he poser from ECRI Insiue, as well as oher resources, is pro-

vided in “ECRI Insiue Resources.”

ECRI INSTITUTE

RESOURCES

HRC 

 Z Prevening Miscon-

necions of Lines andCables

 Z Invasive Lines

Other Memberships

and Sources

 Z Be a T.R.A.C.E.R. noa RACER! (poser)

 Z Choosing a SyringeInfusion Pump (Health Devices)

 Z Fixing Bad Linkso Preven TubingMisconnecions (PSO

Navigator) Z Infusion Pump Ine-

graion: Why Is INeeded and WhaAre he Challenges? (Health Devices)

 Z Paien-ConrolledAnalgesic InfusionPumps: Making aPainless Purchase (Health Devices)

 Z Top 10 Health Technol-ogy Hazards for 2015

 Z Which Smar PumpsAre Smares? Raings for Six Large-VolumeInfusion Pumps (Health Devices)

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A every care ransiion, such as admissions, ransfers, and discharges, “he paien’s medi-

caions should be reconciled o ensure he paien is on he correc medicaions for he nex

phase of care,” says Mary Beh Michell, MSN, RN, CPHQ, CCM, SSBB, paien safey analys

and consulan a ECRI Insiue PSO. Inadequae medicaion reconciliaion pus paiens a

risk for medicaion errors, inadequae follow-up care, and hospial readmissions.

On admission, medicaion reconciliaion is challenging o conduc effecively unless hepaien or family members have kep accurae records of he paien’s medicaions, says

Michell. To ensure he lis’s accuracy, she recommends verifying he paien’s medicaion

lis wih anoher source, such as he paien’s primary care physician and/or pharmacy. The

 backup approach is no fail-safe, however, if he paien goes o muliple pharmacies or is

seen by muliple specialiss, “all of whom may order prescripions for he paien,” she says.

Providers should also ask abou any over-he-couner and herbal medicaions ha he paien

may be aking, as well as any ransdermal paches ha are in place.

A faciliy migh also refer o he paien’s las medical record from a previous say o

idenify he paien’s lis of medicaions a discharge. “Bu ha may no be a good source forinformaion if i’s been a long ime since he paien’s las hospializaion or if he paien has

had medicaion changes by heir primary care physician and/or specialiss,” says Michell.

The paien’s medicaions may have changed if he previous hospializaion was no recen, asin he following even repored o ECRI Insiue PSO and is parner PSOs:

The paien was admited hrough he ED. The paien brough a lis of curren medicaions. The lis

was compared o he paien’s medicaion lis from a previous say. Two oher medicaions, an anipsy-

choic drug and a diabees medicine, from he previous say were no on he paien’s medicaion lis

and were ordered. No one wen over he paien’s curren medicaion lis wih he paien. During he

 paien’s say, he paien’s wife repored he paien was having hallucinaions and seemed coninually

drowsy when ha wasn’ he paien’s norm. I was deermined ha he paien had no aken he wo

addiional medicaions for a year, so hey were disconinued.

When a paien is admited for care, providers may decide o disconinue some or all of

he paien’s medicaions aken before he admission in order o address he paien’s acue

needs. They may also inroduce new medicaions o rea he acue condiion. As he paien’scondiion improves or changes and when he paien is ransferred o anoher level of care,

clinicians mus coninue o evaluae he paien’s medicaion needs, deciding wheher o dis-

coninue he medicaions for he acue condiion, inroduce any new drugs, or resume any of

he medicaions ha he paien ook before admission.

“By he ime he paien is ready for discharge, hey should no be receiving new medica-

ions ha hey did no receive while in he hospial,” says Michell. “The poin of conducing

medicaion reconciliaion every sep along he way of he hospializaion is ha by he ime

he paien is ready for discharge, hey should be on he righ medicaions and he healhcare

providers should know ha he paien can olerae he medicaions when aken ogeher.”

5. Care Coordination Events

Related to MedicationReconciliation

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Top 10 Patient Safety Concerns for Healthcare Organizations

While EHRs can improve communicaion among providers abou paiens’ medicaions,

Michell warns o use he echnology cauiously. For example, a discharge, don’ simply

prin he paien’s lis of medicaions wihou assigning someone o go hrough he lis o look

for errors, such as dosing errors and duplicae orders for similar drugs wih differen names,

she recommends. In addiion, some EHRs allow only one person o reconcile he medicaions,

which means ha ha physician mus be sure of all of he medicaions and recommended

doses from he specialis physicians.

If he paien is being discharged o anoher healhcare seting, medicaion reconciliaion

can only be achieved by effecively managing he paien’s discharge from he hospial and

he admission o he oher faciliy, such as a nursing home or subacue care faciliy, says Rose.

“Boh pieces need o be managed . . . for medicaion reconciliaion o work well,” he says.

If he discharge and admission process from one faciliy o anoher is poorly managed,

paien care can suffer. “Medicaions ha were disconinued a he hospial may no be

resared when he person comes back o an aging services provider or reurns home,” says

Rose. The aging services provider mus hen coordinae wih he hospial and physicianwho was overseeing he paien’s care or he paien’s primary care physician o idenify

he paien’s medicaions. “I’s no an easy process and can lead o delays in resuming he

paien’s care,” Rose says.

Typically, aging services providers conduc char checks wihin 24 hours of a residen’s

reurn o he faciliy afer a hospial discharge o review he residen’s medicaions, o see

if anyhing was sopped or added, and o deermine if here’s a reason for he change, says

Rose. If he residen is new o he faciliy, he organizaion will verify ha informaion wih

he individual’s primary care physician.

There are many ways o manage medicaion reconciliaion. Some publicly available

resources for medicaion reconciliaion recommend pharmacis-led inervenions, bu here

are oher approaches as well. A good mechanism o ensure ha he medicaion reconciliaion

process works well is o proacively evaluae he process using a failure mode and effecs

analysis (FMEA) o idenify gaps in ha process. Consider involving he pharmaciss, case

managers, nursing, and oher FMEA eam members in idenifying soluions o close he gaps,says Michell. “Pharmaciss don’ necessarily need o lead he inervenions, bu hey need o

 be involved wih he mulidisciplinary eam in closing he gap,” she says.

Rose, who also recommends ha aging services providers conduc a similar proacive

analysis of heir medicaion reconciliaion processes, encourages hospials and aging services

providers o engage each oher in he medicaion reconciliaion assessmen. “Find ou where

he risks exis and have inelligen conversaions wih your care parners in he communiy o

pu pracices in place o miigae hem,” he says. Refer o “ECRI Insiue Resources” for addi-

ional informaion.

ECRI INSTITUTE

RESOURCES

HRC 

 Z Discharge Planning

 Z Medicaion Safey Z Subacue Care in

Long-Term CareSetings 

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Top 10 Patient Safety Concerns for Healthcare Organizations

In blood banking, having wo praciioners perform an independen double check of he

 blood group before ransfusion is a long-sanding requiremen. “Nobody in he universe

would hink of doing a blood ransfusion wihou doing an independen double check firs

 because you could kill he paien prety quickly,” saes Elizabeh Drozd, MS, MT(ASCP)

SBB, CPPS, paien safey analys, ECRI Insiue PSO. “Bu for high-aler medicaions, we’ve

seen a lo of conroversy abou doing independen double checks and have seen a lo of fail-ures in ha process.”

The following wo evens repored o ECRI Insiue PSO and is parner PSOs illusrae

how failures in independen double checks can affec paiens:

Paien was receiving a heparin drip, which required a double check per policy. The dosing nomo-

 gram and rae were double-checked appropriaely, bu here was no double check when he nurse

changed he rae on he infusion pump. The drip rae was changed o 18 mL/hr insead of 15 mL/hr,

resuling in an elevaed parial hromboplasin ime wih bleeding from he IV sie.

 An independen double check was no compleed when a paien-conrolled analgesia (PCA) pump

was se, resuling in a 10-fold opioid overdose. Naloxone was adminisered, and he paien was rans-

 ferred o he inensive care uni (ICU).

When double checks are used, one major issue is he failure o conduc hem in a way hais ruly independen. As he second provider, “I wan o check your work oally indepen-

denly of wha you’re elling me,” says Drozd. “I wan o look a everyhing,” such as paien

ideniy, indicaion and appropriaeness, drug or blood ype, dose, programmed infusion rae,

and roue.

To achieve ruly independen double checks, he organizaion needs saff buy-in. “They

have o undersand why independen double checks are done independenly,” Drozd

emphasizes. Imporanly, he process mus be free of he poenial for confirmaion bias. For

example, if he firs provider asks he second provider, “I go 5,000 unis of heparin. Wha do

you ge?” he second provider is already biased oward a specific dose and drug. A provider

may overly rely on he second provider’s check, possibly skipping seps, if he or she expecs

ha simply doing a double check will cach any errors or believes ha he second provider“doesn’ make misakes.”

6. Failure to Conduct Independent

Double Checks Independently

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Top 10 Patient Safety Concerns for Healthcare Organizations

In addiion, he organizaion mus be judicious when deciding which processes require

an independen double check. A common misake is o “add a double check as a soluion o

everyhing,” says Drozd, poenially leading o double check faigue. Insead, “use indepen-

den double checks wih a lo of cauion and only for processes ha could harm he paien

very, very quickly.”

Sysems issues should also be invesigaed. For example, if policies and proceduresrequire an independen double check in a paricular siuaion bu a second provider is ofen

unavailable, saff may use workarounds or even skip he double check.

How can organizaions invesigae wheher hey are performing independen double

checks in a way ha is ruly independen? “The only way, really, is o begin o audi and

observe he acual process,” says Drozd. “You have o be ou here in he paien care areas

and observe,” using a checklis of wha o look for. This approach is labor-inensive, bu

“i’s also your opporuniy o link wih he individuals o explain he imporance of doing i

properly.”

Alhough here are many poenial barriers o ruly independen double checks, he

Insiue for Safe Medicaion Pracices (ISMP) calculaes ha hey can deec up o 95% of

errors. “When done properly, hey do deec a significan amoun of errors,” says Drozd.

ECRI INSTITUTE

RESOURCES

HRC 

 Z Ask HRC: Conduc-

ing and DocumeningDouble-Checks forMedicaion Safey

 Z High-AlerMedicaions

 Z Blood Transfusions

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Top 10 Patient Safety Concerns for Healthcare Organizations

7. Opioid-Related Events

“The use and he prescribing of opioids has significanly increased in recen years,” says

Sephanie Uses, PharmD, MJ, JD, paien safey analys, ECRI Insiue PSO, and “ha’s one

of he reasons opioid safey has become more of an issue.” According o he U.S. Deparmen

of Healh and Human Services’ Naional Acion Plan for Adverse Drug Even Prevenion , he

number of prescripion opioids dispensed doubled beween 1999 and 2010, and by he end of

ha period, he number of relaed deahs exceeded he number of overdose deahs involvingheroin and cocaine combined. The number of ED visis relaed o opioid misuse and abuse

oaled more han 420,000 in 2011—double he number of visis in 2004.

Problems relaed o opioid overdose, such as over-sedaion and respiraory depression,

are a major paien safey concern, bu hey are no he only ones. Oher issues include gas-

roinesinal adverse evens (e.g., nausea, vomiing, consipaion), hyperalgesia, prurius, and

immunologic or hormonal dysfuncion.

Among evens in ECRI Insiue’s PSO daabase, he problem is “no specific o any one

opioid,” says Uses. However, hose commonly involved in evens are hydromorphone, oxy-

codone, opioids used in PCA, and fenanyl paches.

Two issues are especially concerning. Firs, “some of he more common errors wih hydro-

morphone are due o is poency,” says Uses. Hydromorphone is abou seven imes as poenas morphine, bu physicians someimes prescribe he same amoun of hydromorphone

as hey would morphine, leading o overdose, as in he following even repored o ECRI

Insiue PSO and is parner PSOs:

Paien presens o ED wih abdominal pain. The paien’s pain is poorly relieved wih morphine

4 mg; atending physician changes pain orders o hydromorphone 4 mg inravenously every 4 hours

as needed. The paien’s nurse adminisers a dose of hydromorphone. Shorly afer he dose is given,

he nurse noices decreased responsiveness, he paien becomes apneic, and code blue is called. Two

doses of naloxone are given. Paien becomes responsive and is ransferred o he inensive care uni for

monioring.

Second, prescribers someimes fail o disinguish paiens who are opioid-oleran (hose

who have been aking an opioid of a leas a cerain hreshold dosage for a leas a week) fromhose who are opioid-naïve (hose who have no). For example, opioid-naïve paiens should

no be prescribed fenanyl paches, and hese paiens should receive only very low doses of

susained-release oxycodone, if he drug is used a all. They should no receive coninuous

infusion when PCA herapy is iniiaed; raher, bolus-only herapy should be used.

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Top 10 Patient Safety Concerns for Healthcare Organizations

Opioid-relaed evens are no resriced o he hospial. For example, oxycodone and

fenanyl paches may be used in long-erm and ambulaory care setings and a home. In

addiion, family members or friends may inappropriaely ake he paien’s medicaions o

self-rea heir pain, or he drugs may be oherwise misused or abused by he paien or oh-

ers. ISMP has also repored on incidens, including deahs, in children and older aduls wih

cogniive impairmen who have suck fenanyl paches on heir bodies or ingesed hem.“Fenanyl is so poen,” says Uses, “a young child will sop breahing righ away” afer

ingesing or applying a fenanyl pach.

Alhough many sraegies should be employed o promoe safey hroughou he medica-

ion-use process, Uses highlighs a few key inervenions o preven and miigae he kinds of

evens ECRI Insiue PSO is seeing.

Prescribers should be educaed abou opioid safey and he evens ha can resul. One

cenral issue is appropriae prescribing. “Does he paien really require an opioid?” says

Uses. “Someimes ha’s no he firs choice ha we need o go o.” Order ses—wih differ-

en drug forms and dosages for opioid-naïve and opioid-oleran paiens, for example—may

help guide clinicians as well.

In hospials, saff should be rained o monior for sedaion. “A lo of imes, people don’monior for sedaion and don’ recognize sedaion as a problem unil he paien is already

experiencing respiraory depression,” Uses cauions. The Pasero Opioid Sedaion Scale is one

ool ha saff can use o monior for opioid-induced sedaion.

A home and in oher nonhospial setings, paiens and caregivers mus know how o

appropriaely sore and dispose of opioids. These drugs should no be kep in easy view and

reach of ohers, and disposal opions include ake-back days, locked drop boxes, and appro-

priae disposal a home.

To invesigae opioid-relaed evens hey are experiencing, healhcare organizaions can

no only look a heir adverse even daabase bu also use rigger ools—for example, by

running daily repors o idenify when naloxone, a reversal agen, is dispensed. Faser noi-

ficaion allows for easier invesigaion of evens, and “you can rack and rend and see whayour problems are,” Uses noes.

ECRI INSTITUTE

RESOURCES

HRC 

 Z High-Aler

Medicaions Z Pain Medicaion and

PRN Orders

 Z Paien-ConrolledAnalgesia

 Z Infusion Pumps

Other Memberships and

Sources

 Z ECRI Institute PSODeep Dive: MedicationSafety

 Z Pain Relief: How oKeep Opioid Admin-israion Safe (PSONavigator)

 Z Pasero Opioid Seda-ion Scale (POSS)wih Inervenions

 Z Prevening Opioid-Induced RespiraoryDepression (webinarfor ECRI InsiuePSO)

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Top 10 Patient Safety Concerns for Healthcare Organizations

Reprocessing of endoscopes and surgical insrumens, a op 10 paien safey concern and

healh echnology hazard for 2014, reurns o boh op 10 liss for 2015. In fac, reprocessing

has been raised as a op 10 healh echnology hazard for six years in a row.

“We coninue o see reprocessing issues in our acciden invesigaions” and in media repors,

says Schluh. Addiionally, as ECRI Insiue was preparing Top 10 Healh Technology Hazards for

2015 , he Ebola virus had become fron-page news, furher “highlighing he criical imporanceof he reprocessing funcion,” says Schluh.

The poenial harm o paiens from he ransmission of infecious agens remaining on

reusable devices can be severe. More han half of he “immediae hrea o life” findings from

 Join Commission surveys conduced in 2013 were direcly relaed o improper equipmen

reprocessing, Schluh noes.

Healhcare faciliies reprocess housands of reusable surgical insrumens and devices

every day for subsequen use. No only are he devices difficul o clean, bu “muliple seps

are required o ge i righ,” says Keller. Each sep mus be properly performed from sar

o finish. For example, if he devices are no horoughly cleaned, organisms may remain on

he devices, unaffeced by disinfecion or serilizaion. Similarly, if he devices are no hor-

oughly dried in he final reprocessing sep, “hey are a breeding ground for organisms ogrow posprocessing,” says Keller.

8. Inadequate Reprocessing

of Endoscopes and SurgicalInstruments

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©2015 ECRI Institute.APRIL 2015 23

Top 10 Patient Safety Concerns for Healthcare Organizations

ECRI INSTITUTE

RESOURCES

HRC 

 Z Reprocessing of

Flexible Endoscopes Z Reprocessing in

Cenral Service

 Z Endoscope Reprocess-ing: The Imporanceof Being Proacive 

Other Memberships

and Sources

 Z CRE and Duodeno-scope ResourceCener

 Z Clear Channels:Ensuring Effecive

Endoscope Repro-cessing (HealthDevices) 

Z Inadequaely Repro-cessed Insrumens:If I’s Diry, How CanI Be Clean? (PSO

 Monthly Brief )

 Z Serile ProcessingDeparmen’s Role inPaien Safey (PSONavigator)

 Z Top 10 Health Technol-

ogy Hazards for 2015

Furher complicaing he reprocessing funcion are he muliple ypes of devices, each

wih heir own cleaning and disinfecion or serilizaion insrucions, says Keller. If auo-

maed reprocessing sysems are used for endoscope disinfecion, each device model will

likely require unique model-specific channel adapers o properly flush each channel of he

device, he adds.

Any ime a change is inroduced o reprocessing, such as a new disinfecan, cleaningagen, or channel cleaning brushes, he impac of he change needs o be evaluaed for any

ripple effec on he qualiy of he process. For example, afer being asked o invesigae

an infecion oubreak in an endoscopy clinic, ECRI Insiue discovered ha he clinic had

swiched o a new cleaning soluion ha required a longer soak ime for insrumens han

required wih he previously used cleaning soluion. The clinic’s reprocessing procedures

were no longer effecive, because he clinic had no adjused he insrumen soak ime

required wih he new soluion.

In addiion o he recommendaions for ensuring adequae device reprocessing lised

in Top 10 Healh Technology Hazards for 2015 , oher guidance from ECRI Insiue is lised in

“ECRI Insiue Resources.”

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Top 10 Patient Safety Concerns for Healthcare Organizations

“Transporing a paien wihin he hospial o anoher clinical seting or beween unis

wihin he faciliy presens risk of harm o he paien and, depending on he needs of he

paien, can be an unsetling experience for nurses charged wih caring for he paien, and

for he ransporer,” says Kelly Graham, BS, RN, paien safey analys a ECRI Insiue PSO.

Safe ranspor involves idenifying and providing appropriae resources and requiremens

for each paien during ranspor and includes proper handoff communicaion o and fromappropriaely rained ransporers. Paiens may be ranspored o he wrong deparmen,

he wrong paien may be ranspored, or paiens may be lef unmoniored a he receiving

sie. A sandardized process for paien ranspor and handoff communicaion can reduce risk

during ranspor and a he sending and receiving ends of he process, Graham says.

Risks of ranspor vary wih paien acuiy. “Ideally, he level of care provided dur-

ing ranspor pairs wih he care he paien receives in he uni,” Graham adds. Criically

ill paiens, for example, are exposed o periods of poenial insabiliy during ranspor.

Mainaining oxygenaion during ranspor and acivaing a code when a paien’s condiion

rapidly deerioraes during ranspor are bu a few examples of poenial risk.

To enhance safey, criically ill paiens are ypically ranspored by eams of qualified crii-

cal care providers wih defined roles for monioring and ensuring venilaor suppor. Theranspor process and relaed communicaion is guided by formal policy reflecing guidelines

from he Sociey of Criical Care Medicine and he American College of Criical Care Medicine

for ransporing criically ill paiens. Bu because danger is inheren in he ranspor process of

all paiens, faciliy ranspor policy and procedures should guide handoff communicaion for

he safe ranspor of he non-ICU paien.

The Join Commission requires ha each paien handoff communicaion include a

sandardized and ineracive approach for he safe ransfer of a paien from one care area o

anoher. Handoffs are an inegral par of safe ranspor, and wihou careful atenion o hand-

off communicaion and ranspor safey a each poin in he ranspor process, errors can occur,

Graham says.

Noably, of 2,390 paien-ranspor-relaed repors submited o he Pennsylvania PaienSafey Auhoriy from May 2004 hrough Sepember 2008, 41% involved communicaion

issues, according o an aricle in he March 2009 Pennsylvania Paien Safey Advisory. ECRI

Insiue PSO and is parner PSOs have received repors involving ineffecive handoffs in

he paien ranspor process ha have conribued o paien harm in a variey of care se-

ings. The following repor provides an example of inadequae handoff communicaion

during ranspor of an infan wihin a hospial:

Immediaely afer undergoing a surgical procedure, he infan was ranspored o he neonaal

inensive care uni (NICU) in an open crib. Saff in he uni had no been informed ha he infan’s

9. Inadequate Patient Handoffs

Related to Patient Transport

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Top 10 Patient Safety Concerns for Healthcare Organizations

ECRI INSTITUTE

RESOURCES

HRC 

 Z Communicaion

 Z Safe Paien MobiliyPolicy andProcedure

Other Memberships

and Sources

 Z Handoffs: Oppor-uniy for Safe Care (PSO Navigator)

body emperaure dropped in he operaing room (OR), or ha he infan was ranspored direcly

 from he OR o he uni, and ha he infan had no been moniored in a recovery uni. A nurse pre-

 paring he infan for he NICU say expressed concern abou he infan’s pale coloring and slowed

respiraion. The baby was given vigorous spinal simulaion in an effor o resore breahing and

reurn body emperaure o normal, and required inubaion when breahing did no fully respond o

he spinal simulaion.Graham recommends ha faciliies’ even and near-miss reporing sysems capure

ranspor-relaed incidens and near misses ha occur “off uni” and during ranspor. Such

repors can idenify gaps in policies, procedures, or raining; he need for improved com-

municaion processes and oversigh for follow-up and monioring of handoff proocols; and

oher problems ha may require reassessmen of ranspor policies and procedures.

Graham suggess ha ranspor policies and procedures be based on consideraion of

numerous issues, he following among hem:

X Idenifying unis are mos ofen involved in ranspor and safey hazards paricular o

he unis

 X Developing crieria for deermining he level of ranspor eam needed (depending on

paien assessmen and he level of care required)X Ensuring availabiliy of equipmen, assigning responsibiliy for mainenance of hera-

pies during ranspor, and roubleshooing equipmen during ranspor

 X Deermining raining, experience, and compeency required of ranspor personnel

in ligh of expeced levels of inervenion ha may be required during ranspor

 X Developing and implemening ools and checkliss o suppor handoff communicaion

among he care eam, ranspor personnel, and saff a he receiving sie

Policies and procedures migh incorporae use of a ranspor form, ofen referred o as

a “Ticke o Ride” form, ha helps convey essenial informaion from he sending uni,

provides a checklis o be addressed by ranspor saff and by he receiving uni, and incor-

poraes a siuaion-background-assessmen-recommendaion (SBAR) forma o enhance

communicaion a each end of he process. ECRI Insiue has also developed handoff com-municaion sraegies ha address ranspor. For addiional informaion, see “ECRI Insiue

Resources.”

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Top 10 Patient Safety Concerns for Healthcare Organizations

The paien safey evens presened in his repor are no jus saisics, as he issue of pound-

kilogram mix-ups illusraes. “We definiely see hese evens in he PSO daa,” says Sheila

Rossi, MHA, paien safey analys/consulan, ECRI Insiue PSO. Bu she gained a firs-

hand undersanding of he issue hrough her own personal experience.

On a visi o a local ED, Rossi’s wo-year-old son was weighed in he riage room. Laer,

he physician deermined ha he needed wo oral medicaions, o be given by Rossi and herhusband. “Having previously given him wo similar medicaions a home, we had some

idea of he dosing based on his age and weigh,” Rossi says. When he nurse brough in wo

 big syringes, Rossi and her husband said, “Wow, ha looks like a lo of medicaion,” and

quesioned he amoun. “Almos in unison, he nurse and he docor said, ‘I’s weigh-based

dosing.’” Sill rusing heir insinc ha somehing wasn’ righ, Rossi and her husband gave

heir son a porion of each dose, disposing of he excess in a napkin, afer he providers lef

he room.

The nex morning, he physician called and apologized, informing Rossi ha here had

 been a mix-up in he weigh-based calculaion. Their son had been weighed in pounds, bu

his 30-pound weigh had been enered ino he EHR as 30 kilograms (equivalen o abou 66

pounds). The oral syringes had each conained roughly wice he amoun of medicaion heshould have received; forunaely, neiher was a high-aler medicaion. Bu, says Rossi, “My

concern wasn’ so much for my child; my concern was for he nex child ha comes along

and wha sysem fixes hey were going o make so ha his would no occur again.”

Mix-ups beween pounds and kilograms are no limied o EDs and hospials; hey can

happen “anyplace ha has a scale,” says Rossi. And alhough he problem poses “a huge

poenial for error wih aduls,” children and older aduls may be even more sensiive o

medicaion dosing errors. Similarly, overdoses involving high-aler medicaions pose a par-

icular paien safey concern. Consider he following even repored o ECRI Insiue PSO

and is parner PSOs, which involved an older adul:

Weigh was enered in he EHR incorrecly. The employee used pounds for kilograms. A low-molec-

ular-weigh heparin was dosed for more han double he paien’s weigh. The pharmacy discovered heerror, and he order was disconinued. The anicoagulaion saus of he paien was moniored.

10. Medication Errors Related to

Pounds and Kilograms

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Top 10 Patient Safety Concerns for Healthcare Organizations

ECRI INSTITUTE

RESOURCES

HRC 

 Z Medicaion Safey:

Inaccurae PaienWeigh Can CauseDosing Errors

 Z Medicaion Safey

Other Memberships

and Sources

 Z Medicaion Safey:Inaccurae PaienWeigh Can CauseDosing Errors (PSONavigator)

One of he mos effecive sraegies o reduce he risk of such errors is o “ge rid of scales ha

measure in pounds,” says Rossi. There are many barriers o employing his sraegy. For exam-

ple, i requires subsanial capial, and parens ofen wan o know heir child’s weigh in pounds.

Alernaives may include adjusing elecronic scales so ha hey display only in kilograms and

giving parens weigh conversion chars. “If you can ge rid of ha mix-up a he very firs sep in

he process, pounds are never inroduced ino he equaion,” says Rossi.Oher high-impac sraegies include he following:

 X Ensuring ready availabiliy of pediaric scales (e.g., o reduce reliance on parenal 

esimaes, which are likely o be in pounds)

 X Recording and displaying weigh only in kilograms in he EHR

 X Inegraing digial scales wih he EHR o eliminae or reduce he need for daa enry

 X Using clinical decision suppor funcions ha compare enered weigh wih expeced

weigh (e.g., based on growh chars)

 X Purchasing infusion pumps wih dose error reducion feaures

 X No soring in clinical areas any high-aler drugs or oher medicaions ha have he

poenial o cause paien harm if weigh-based doses are miscalculaedTo invesigae his issue, organizaions may sar by reviewing heir even-reporing sys-

ems. Bu ha may yield limied informaion because “i assumes ha people are acually

reporing hese evens as weigh-based errors,” Rossi noes. Char audis and observaion

can help he organizaion explore furher. “How are paiens being weighed, wha scales are

used, how is he weigh enered ino he EHR, where are he chances for error?” says Rossi.

Rossi’s encouner offers some moivaion and perspecive for all paien safey evens.

“When we say ‘he paien’ in healhcare, i someimes becomes impersonal, and we see he

paien as someone else, a body or objec o which care is delivered and in some cases bad

evens or oucomes occur. We have all been or will become ‘paiens’ a some poin in our

lives,” says Rossi. “How are we going o improve paien safey for ourselves? How do we pu

ourselves in he paien’s shoes and say, ‘How do I preven his from happening o me?’”

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 Z UNITED STATES

5200 Butler Pike,

Plymouth Meeting, PA

19462-1298, USA

Telephone +1 (610) 825-6000

Z EUROPE

Suite 104, 29 Broadwater Road

Welwyn Garden City,

Hertfordshire, AL7 3BQ, UK

Telephone +44 (1707) 871 511

Z ASIA PACIFIC

11-3-10, Jalan 3/109F,

Danau Business Centre,

Taman Danau Desa,

58100 Kuala Lumpur, Malaysia

 Z MIDDLE EAST

Ofce No. 1101, 11th Floor,

Al Shafar Tower 1, TECOM

P.O. Box 128740

Dubai, United Arab Emirates