Developing the top 10 patient safety list every year comes down to a group of ECRI Institute experts culling through submitted event reports, conducting accident investigations, and looking at the consulting projects they do. Every year, the consensus distributes a lists the top 10 concerns. Cindy Wallace, CPHRM, senior risk management analyst at the institute, shares some concerns that did not make this year’s list.
The Joint Commission released a health IT-related Sentinel Event Alert this spring. There was another one in 2008 related to the convergence of technology regarding electronic health records and devices. Since then, organizations have been informing stakeholders of the concerns they should have and care they should take related to technology that, when used properly, can make the lives of frontline staff easier and the care of patients safer and of higher quality.
The Joint Commission recently studied 120 Sentinel Events, a third of which were related to human-computer interface. Think of a case where you chose the wrong item from a drop-down menu, or if you had two files open and clicked the wrong one. Clinical content was nearly a quarter of them. That relates to design issues related to clinical content, like the ability to have two EHRs open at once. Another quarter were workflow and communication issues. Three issues each had 6%: policies/procedures/culture, people (training or failure to follow the procedures in place), and software or hardware issues.
No one would say that modern medicine is perfect or that it is free of bad actors. Yet, most of those involved in dealing with the repercussions of Recovery Audit Contractor audits have probably sighed in exasperation over the length of time an appeal takes.
If there is a Sentinel Event and you do a root cause investigation, you may start by looking at what time something occurred. But if you look at an infusion pump, it might give you a completely different time than the heart monitor. Why? Because there is no central device that synchronizes time for devices. This is one of the examples of the lack of interoperability between devices and the potential problems it can cause hospitals.
You can get a lot of data from more than 350 million hospital admissions. What you hope to find is that the care is equivalent from day to day, patient to patient. But that is not the case. According to a study published in April in BMJ, patients who are admitted on the weekend are more likely to fall or experience some other adverse event.
It’s been nearly 10 years since the Institute of Medicine (IOM) issued a report stating that hospitals needed to be better prepared for the smallest and youngest patients when they came into their emergency departments