This appeared last week:
Diagnostic errors, opioid safety top ECRI's top 10 patient safety priorities for 2018
by Matt Kuhrt
Mar 13, 2018 9:55am
Healthcare facilities looking to prioritize their patient safety efforts should start by focusing on diagnostic errors and opioid safety, according to the ECRI Institute.
Those measures led the organization’s list of the top 10 patient safety concerns for 2018. The ECRI Institute develops its annual list through a review of event reports and root-cause analyses from its members and intends for hospitals to use the information in support of their individual efforts to identify and mitigate patient safety issues.
Diagnostic errors are commonplace and carry a high potential for adverse consequences, according to Gail M. Horvath, R.N., a patient safety analyst at the ECRI Institute.
“A lot of hospital deaths that were attributed to the normal course of disease may have been the result of diagnostic error,” she said.
The frequency with which diagnostic errors occur and the relative difficulty hospitals have in monitoring for such mistakes have driven recent innovations in clinical decision support systems, which Horvath recommends as a first line of defense.
Recent innovations in clinical support include a Johns Hopkins program that uses statistical analysis to help quickly identify troublesome patterns and predict symptoms likely to create issues.
Opioid safety across the care continuum occupied the second slot on the list, echoing widespread concern about an epidemic of abuse in the United States.
The full article is here:
Here is the press release:
News Release
Diagnostic Errors Top ECRI Institute’s Patient Safety Concerns for 2018
New report examines root causes for serious patient safety events
3/12/2018
“Diagnostic errors are not only common, but they can have serious consequences," says Gail M. Horvath, MSN, RN, CNOR, CRCST, patient safety analyst, ECRI Institute. "A lot of hospital deaths that were attributed to the normal course of disease may have been the result of diagnostic error."
ECRI Institute suggests using structured tools and algorithms to help overcome cognitive biases that can lead to errors. When errors or near misses occur, organizations can capture data using a variety of methods and then develop non-punitive ways of learning from the errors.
“Clinical decision support interventions can also be helpful by identifying ordered tests that haven't been done or by flagging incidental findings that require follow-up," adds Horvath.
Opioid safety, second on this year's list, stretches across the healthcare continuum. “Opioids are a patient safety concern because of the seriousness of the side effects," says Stephanie Uses, PharmD, MJ, JD, patient safety analyst and consultant, ECRI Institute. "We recommend that clinicians carefully assess patients for opioid use disorder and set realistic expectations about pain."
ECRI Institute's 2018 list of patient safety concerns:
- Diagnostic errors
- Opioid safety across the continuum of care
- Care coordination within a setting
- Workarounds
- Incorporating health IT into patient safety programs
- Management of behavioral health needs in acute care settings
- All-hazards emergency preparedness
- Device cleaning, disinfection, and sterilization
- Patient engagement and health literacy
- Leadership engagement in patient safety
"The list does not necessarily represent the issues that occur most frequently or are most severe. Most organizations already know what their high frequency, high-severity challenges are," says William Marella, MBA, MMI, Executive Director, Operations and Analytics of Patient Safety, Risk and Quality, ECRI Institute PSO.
“Rather, this list identifies concerns that have appeared in our members' inquiries, their root cause analyses, and in the adverse events they submit to our Patient Safety Organization," adds Marella.
ECRI Institute PSO has received more than 2 million event reports and reviewed hundreds of root-cause analyses since 2009.
Healthcare organizations can use ECRI Institute's 2018 Top 10 Patient Safety Concerns for Healthcare Organizations to identify priorities and create corrective action plans. ECRI Institute is providing open access to the Executive Brief at www.ecri.org/PatientSafetyTop10. The comprehensive report, available to ECRI Institute members, includes many additional resources.
ECRI Institute encourages organizations to adapt relevant patient safety interventions to meet each care setting. Although not all patient safety concerns on the list apply to all healthcare organizations, many are relevant to a range of settings across the continuum of care.
For information about working with ECRI Institute PSO, call (610) 825-6000, ext. 5558; e-mail pso@ecri.org; visit www.ecri.org/pso; or write to us at 5200 Butler Pike, Plymouth Meeting, PA 19462.
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This is important stuff and should be read by all interested in patient safety.
Downloading the brief is well worth while.
David.
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