Investigations conducted by ECRI found hospitals often either failed to have protocols or had inconsistent ones. It's a timely issue, ECRI says, as hospitals need to implement protocols to meet new Joint Commission requirements taking effect in 2016.
Data integrity issues related to missing, incorrect or incomplete information in EHRs was next on the list, a concern for the second year in a row. Examples includes a patient's data appearing in another patient's record, outdated information copied and pasted repeatedly and default values populating fields with erroneous information.
Several concerns on the list have a health IT component. “Information technology is pervading healthcare delivery today in a way it did not 10 years ago,” Marella said. “It's enabling us to do things we couldn't do before … but as with any disruptive technology, it also can have unintended consequences.”
For example, No. 5 on the list was inadequate care coordination during medication reconciliations, since overreliance on EHRs can compromise the process. Also No. 10, medication errors linked to pound-to-kilogram conversions, can be compounded by default values in the electronic systems.
No. 8 on the list is the reprocessing of surgical instruments and endoscopes. Scopes are used in more than 500,000 procedures each year, but were recently connected with two highly publicized outbreaks of drug-resistant bacteria.
The list also points to issues associated with the managing of patient violence. A worker could face up to 15 incidents of patient violence a day according to No. 3 on the ECRI list. This week a 25-member panel of experts convened by the American Nurses Association issued a draft report that includes recommendations on preventing and reducing workplace violence. That report will be available for public comment through April 30.
The list also highlights IV line mix-ups; failures to conduct independent double checks; opioid-related events and inadequate patient handoffs, all of which Marella says are perennial problems. Though the items are ranked according to frequency of events reported through ECRI's patient-safety organization, hospitals will want to prioritize the concerns based on their individual organization's needs and those of their patient population, he said.