Vital Signs Blog

Blog: Objects left in patients and health IT issues among top safety woes

Hospitals continue to struggle with long-standing patient safety issues, such as leaving sponges and towels inside of patients having surgery and failing to create a culture where staffers speak up about mistakes.

That's according to the third annual report on the year's top patient safety issues from the ECRI Institute, a not-for-profit health research agency.

A panel of patient safety analysts distilled the top 10 concerns from ECRI's adverse event reporting system, accident investigations and visits to healthcare provider sites. The list details serious issues that providers experience, despite concerted efforts to avoid them, the report says.

But not all are specific to inpatient care. Most carry over to ambulatory and nursing home settings as well, said Bill Marella, director, patient safety reporting programs and analytics for the institute.

The panel debated whether to include the challenge of embracing safety culture and a blame-free environment. Ultimately, it was labeled the 10th most common issue. While mistakes can happen in any industry, healthcare providers have been urged to institute learning-system approaches.

“That's where the rubber meets the road ... but there's not been a whole lot of movement,” Marella said. People still feel adverse events are held against them, which inhibits crucial conversation about things going wrong. “It's too easy to point the finger, and not go deeper to look at the systemic causes,” he added.

Much of the list did focus on systemic issues. For example, healthcare information technology was among the top concerns for the third year in a row. This year, concerns revolved around proper integration of new information technology into the workflow. Previous lists called out missing or incorrect data in electronic health records and data integrity failures.

One ongoing problem is leaving surgical items inside patients, a concern highlighted in the eye-opening patient safety report released by the Institute of Medicine in 1999.

Earlier this year, the Joint Commission, which accredits U.S. healthcare facilities, said retained objects was the most frequent preventable event reported in 2015, with at least 115 reports logged through its voluntary reporting system.

The issue has never been adequately addressed, despite new technology that can track objects inserted into patients, said ECRI's Marella. “The technology is not used by everybody … and even when used, it doesn't catch everything.”

The ECRI institute began issuing its annual report in 2014. The organization recommends solutions for each of the 10 items on the list and provides links for resources to address each problem.

This year's report highlights misidentifying patients, poor management of patients with behavioral health issues, inadequate cleaning of endoscopes, failure to follow-up on important test results, not monitoring patients taking opioids for respiratory depression, pounds-kilogram mix ups, and not having programs to avoid what the report calls “an antibiotic apocalypse."

In March, the White House announced a five-year “national action plan” to curb the threat caused by increasing number of bacteria-resistant to antibiotics.

By 2020, all healthcare settings will be expected to establish programs for proper antibiotic use, with a goal of reducing inappropriate use of the drugs by 50% in outpatient settings and by 20% in inpatient settings.


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