Pediatric mental health, workplace violence are top 2023 safety concerns: ECRI

Pediatric mental health, violence against clinicians and uncertainty around reproductive care are among the most pressing issues for health system leadership to address this year, according to ECRI’s 2023 list of top 10 patient safety concerns. 

Gone from the list is last year's top concern—understaffing. Also missing are past themes of inequity and racism in healthcare, disjointed telehealth workflows and emergency preparedness. The list stems from recent studies, patient safety databases and in-depth conversations with industry stakeholders.

The report, released Monday by the nonprofit patient safety organization, also advises systems on how to solve industrywide problems such as delayed sepsis treatment, medication errors and preventable harm due to missed care. 

Instead of looking at these issues as individual events to address, stakeholders need to come together as part of a comprehensive effort to prevent harm, said Dr. Marcus Schabacker, president and CEO of ECRI.

“We have not made enough progress when it comes to patient safety,” Schabacker said. “What's lacking is the total system safety approach. It starts with a culture of leadership and the governance you put in place where there's a deep and believable commitment to safety.”

While this year's list doesn't share some of the same issues as previous lineups, many prior concerns continue to have an underlying impact on the areas being highlighted, said Patricia McGaffigan, vice president of the Institute for Healthcare Improvement. 

Staffing shortages in particular have caused adverse events in care coordination and medication administration, and have also led to clinicians being forced to work outside their scope of practice.

“There's a certain interdependency and connectedness here that is vital," McGaffigan said. 

The crisis of pediatric mental health 

While they may not receive as much attention as patient safety concerns, children’s mental health issues are reaching a critical point nationwide and need to be acknowledged as one, Schabacker said. 

Since the emergence of COVID-19, pediatric mental health has been steadily declining, worsened by a lack of qualified personnel and access to specialized care, he said. 

In 2020, a nearly 30% increase occurred in children ages 3 to 17 experiencing anxiety and depression compared with 2016, according to a 2022 report by the Health and Human Services Department.

Separately, the weekly average of emergency department visits for suicide attempts among teenagers was 39% higher during the winter of 2021 than during the same period in 2019, a 2021 report by the Centers for Disease Control and Prevention found. 

“Based on where we are in the pandemic, I'm not surprised to see pediatric mental health crisis at the top of the list,” said Stephanie Mercado, CEO of the National Association for Healthcare Quality. “Our kids went through a lot, even in the best of circumstances and the most well-supported environments.”

Clinical staff are not always prepared to support the volume of patients coming in with mental health issues, and the industry’s inability to scale its support for young people is also a population health issue, Mercado said. 

As a start, healthcare facilities should implement universal screening for depression, anxiety, substance use and suicidal ideation for pediatric patients at every visit and form a team of leaders and frontline staff to evaluate their existing gaps in meeting behavioral health needs, Schabacker said.

Physical and verbal violence against clinicians

Next on the list of concerns is the increasing prevalence of attacks on healthcare workers. Around 48% of nurses reported experiencing an increase in workplace violence in April 2022, up from 30% in September 2021, according to a survey by National Nurses United.

During 2022's second quarter, more than 5,200 nursing personnel were assaulted, with most assaults committed by patients in psychiatric units, emergency departments and pediatric units, according to Press Ganey’s National Database of Nursing Quality Indicators. 

“Workforce safety is a driver of patient safety,” Mercado said. “They are inextricably linked. When the workforce feels safe, they will be able to do their best work. If they are afraid to go to work and do not have that psychological safety, they're going to struggle to bring all of their knowledge, skills and abilities.”

The anticipation and expectation of violence is also a driver of clinicians leaving the workforce, she said. 

Rather than adding more security officers to care settings, system leaders should work on identifying issues that contribute to patient outbursts, such as staffing shortages, inefficient emergency departments and socioeconomic factors in certain locations, Schabacker said.

Leaders can then address the problem holistically, assessing risk for workplace violence, forming a trained behavioral emergency response team and developing processes such as a post-incident response that ensures the mental and physical safety of affected employees, he said.

Uncertainty surrounding abortion and reproductive care

Another major area of concern in this year's list is the shifting legal landscape of maternal and fetal care. Following the Supreme Court’s June 2022 decision to overrule Roe v. Wade, clinicians face uncertainty around the legality of providing various reproductive services, with the potential to cause additional worker burnout and harmful delays in care.

Limited clarity exists on providers’ ability to prevent harm to pregnant patients in states that generally prohibit abortions, as well as their ability to prescribe abortion medication via telehealth and provide assistance to patients across state lines, Schabacker said.

It should be system administrators’ responsibility to take charge and give clinical staff clear guidance on the legality of certain services before an urgent medical situation occurs, he said. Leadership needs to be proactive in reviewing all maternal-fetal care processes that may be affected by changes in state law, educating patients and advising clinicians on how to mitigate challenging situations, he said.

In general, health systems should see top patient safety concerns as problems likely already happening within their organizations and reflect on what factors may be contributing to patient harm, McGaffigan said.

“If we keep putting piecemeal solutions in place without addressing the wider opportunities, we'll continue to see some of these challenges remain on the list for years to come,” she said. “What's essential is improving the ecosystem of safety to support all of the concerns that could arise.”