Failures in health information technology topped the list. The federal government provides incentive payments to eligible physicians and hospitals trying to demonstrate meaningful use of electronic health-record technology, however poor design and implementation of the programs can lead to data entry errors, mix-ups in records and incorrect treatments, according to the report.
Problems with interoperability and interface were commonly reported in this category, Zimmer said. Examples include a transplant database not being connected to the hospital's main system, or a patient's list of allergies being noted in the emergency department, but never making their way to the inpatient system when the patient is admitted, she said.
Poor coordination, or gaps in care as patients transfer between members of their care team or even different facilities, was the 2nd concern. The report cites examples of life-saving information on a patient's hospital summary not being provided to the primary care physician, and a communication breakdown between a hospital and rehabilitation facility possibly resulting in the patient's death. Information transfer is a shared responsibility, the report says, but there are often missed opportunities for successful coordination.
Third on the list were issues associated with delays in, and sometimes the complete lack of, reporting test results. Mislabeled laboratory specimens were noted later, as the 6th concern. Last week, the institute issued a deep dive looking at lab results, and found, contrary to what many hospitals might think, most of these types of errors aren't originated in the lab. Close to 75% of mistakes occurred when tests were selected and ordered, when specimens were identified and transported, or when patients were prepped for the tests.
Other concerns making the top 10 included drug shortages, poor management of patients with behavioral health problems, items being left inside patients during surgery, falls, inadequate monitoring of respiratory depression in patients taking opioids, and inappropriate cleaning and disinfecting of surgical instruments.
The list was compiled using data from more than 1,200 hospitals who voluntarily report events through ECRI Institutes safety-event reporting system. More than 20 potential patient safety concerns were originally identified. The final list reflects the top choices of a multidisciplinary team, which ranked and ordered the items. Suggested strategies for approaching each concern are included within the report.
“Use the list as a starting point to ask whether any, some or all of these areas are identified by your organization,” Zimmer said. It's a means of enhancing and informing internal decisions about patient safety, she said.
Follow Sabriya Rice on Twitter: @MHSRice
