Cindy Wallace, CPHRM, Senior Risk Management Analyst and chief author of the annual ECRI Top 10 Patient Safety Concerns for Healthcare Organizations, wants to emphasize: Every hospital will have its own top 10 list. Yet she and her colleagues know that most of these concerns will resonate with most readers.
The 10 chosen safety concerns are:
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Alarm hazards: inadequate alarm configuration policies and practices.
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Data integrity: incorrect or missing data in EHRs and other health IT systems.
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Managing patient violence.
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Mix-up of IV lines, leading to misadministration of drugs and solutions.
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Care coordination events related to medication reconciliation.
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Failure to conduct independent double checks independently.
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Opioid-related events.
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Inadequate reprocessing of endoscopes and surgical instruments
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Inadequate patient handoffs related to patient transport.
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Medication errors related to pounds and kilograms.
Half of the list are new concerns, or at least are a new iteration.
The primary concern, alarm hazards, has been a topic of interest for well over a year in healthcare. Alarm hazards are listed in The Joint Commission’s requirements for certification starting in 2016, and have appeared on ECRI Institute’s technology watch list every year since it began.
What is different about this particular note of concern, William Marella MBA, Executive Director of the patient safety, risk and quality group notes, is that it relates to problems that are related to alarm fatigue — although that remains a problem. Rather, this is about alarms not working properly or going off as they should or when they should. One problem might be a tendency to use factory default settings regardless of where the patient is being cared for while a patient in the NICU is certainly different than a patient in an observation unit.
Still, do not discount alarm fatigue in your search for proper configuration. Marella relates the story of one accident investigation where “everyone was ready to point the finger at the nurse. The alarms sounded, the messages were relayed to her pager, the pager went off, and she acknowledged them,” he says. But when they investigated further they found her pager had been pinged 400 times in a single shift.
Managing patient violence is not technically a new addition, and doesn’t have the requisite asterisk in the ECRI Institute report. However, says Wallace, last year the focus was on behavioral health patients. Now, they have removed that distinction.
The second completely new item on the list is the mix up of intravenous lines, or “spaghetti syndrome,” says Wallace. “This is particularly a problem in the ICU, where you might have patients on multiple drips.” Imagine a patient who is on a saline drip and a heparin drip, she says. One goes in at a higher rate than the other, and one is much more dangerous than the other. Making sure the right line is attached to the right back can be a life or death issue. Recommendations include to trace back lines, to put different drugs on different sides of patients, or more clearly label the lines.
Failure to conduct independent double checks independently sounds more like a mouthful of too many words than a problem hospitals need to conquer, but it is a real safety issue, Marella says. “If you are doing a double check and say to someone, ‘Can you double check this heparin line for me?’ you are biasing that person to find it is, indeed a heparin line.”
The Institute for Safe Medication Practices says than 95% of medication errors can be detected with independent double checks. Marella says you should figure out which medications require them, then make sure the staff is available to ensure they are done, or they will find workarounds that can compromise safety.
Inadequate patient handoffs related to transport, particularly between units, is something that Hospital Peer Review looked at in the January 2015 issue with the Ticket To Ride program in Pittsburgh.
(For more information, see “Improving transitions within the hospital” in the January 2015 issue of Hospital Peer Review.)
Those who transport patients are not often read into special needs that some of them may have. Take a patient with oxygen needs, add to that the labyrinthine nature of hospitals, some of which extend across multiple buildings, and a request for a patient to appear somewhere else for a test. You could end up with a patient decompensating over a long ride simply because you did not tell the aide that the patient might need oxygen, says Marella. “People, including transport aides, need to have situational awareness,” he adds.
Wallace mentions the case of a baby transported to the NICU with a fluctuating temperature but was not relayed to either the transporter or the NICU. “They weren’t closely monitoring the patient and there was a serious event as a result.” Happily, she reports, the patient survived, but the event did not need to occur. Even if the NICU hadn’t known, if the transporter had, it would have been a safety net of information transfer.
Last on the new list is medication errors related to converting pounds to kilograms. (For more on this topic, see story on pediatric emergency room readiness) “Pediatricians actually are pretty good about this, and oncologists,” says Marella. But what if a hospitalist or resident is taking care of that patient? “This is completely solvable,” he says. “If we could convert to the metric system, even just in hospitals, that would help.”
Many EHRs still allow documentation either way, leaving it open to enter pounds into a kilogram field. The best have computer logic that catching these errors, he says. “If you have a two-year-old child and you enter 30 pounds into the kilogram field, the EHR should be able to recognize that weight as off-the-charts high and prompt you to correct it.”
Wallace says the other option is to remove scales recording in pounds or if they have a toggle that lets you switch between, make sure they are as permanently put on kilograms as possible.
The list is a quick look at what has appeared on the desks of investigators and consultants at ECRI Institute, Marella says. “Our intent is that hospitals take this as an opportunity to take stock and see which of these apply to you and your patient populations. Ask probing questions about if you have good processes in place for identifying and preventing problems.”
If you lack resources to adequately address these issues, and you have identified them as problems, Wallace says this report is good to put in front of leadership, since it is based on a nationally compiled database of information — some 1 million events from about 40 states. “Maybe it will help you get resources and support.”
All of these are common enough that most hospitals should be looking to see if they exist. Not all will apply to every hospital, Marella says. Nor is it likely that any hospital has dealt with them uniformly. “Some may have good processes in place for some, but I bet if you looked at your malpractice claims, you find something here to work on. That should help you gain support to deal with these problems, too.”
A complete copy of the report is available on the ECRI Institute website at http://bit.ly/1F1zcXk.
For more information on this topic contact:
• William Marella, MBA, Executive Director, Operation and Analytics, Patient Safety, Risk, and Quality Group, ECRI Institute, Plymouth Meeting, PA. Telephone: (610) 825-6000.
• Cindy Wallace, CPHRM, Senior Risk Management Analyst, ECRI Institute. Plymouth Meeting, PA. Telephone: (610) 825-6000.
