ECRI Institute Releases Annual List of Top 10 Patient Safety Concerns

March 14, 2017
Healthcare providers have troves of information to manage, and the advent of electronic health records (EHRs) has brought this challenge to the forefront, which is why the ECRI Institute cited information management in EHRs as its top patient safety concern in its annual executive brief.

Healthcare providers have troves of information to manage, and the advent of electronic health records (EHRs) has brought this challenge to the forefront, which is why the ECRI Institute cited information management in EHRs as its top patient safety concern in its annual executive brief.

The ECRI Institute, a non-profit organization focused on improving the safety, quality and cost-effectiveness of patient care, on Monday released its fourth annual Top 10 Patient Safety Concerns for Healthcare Organizations executive brief. According to the ECRI Institute, the annual list is meant to guide healthcare organizations on where to direct their patient safety initiatives.

In selecting this year’s list, the ECRI Institute relied on its Patient Safety Organization (PSO) event data, concerns raised by healthcare provider organizations, and on expert judgment to select the topics for the 2017 list. Since 2009, when ECRI Institute PSO began collecting patient safety events, the PSO and partner PSOs have received more than 1.5 million event reports and reviewed hundreds of root cause analyses.

“The 10 patient safety concerns listed in our report are very real,” Catherine Pusey, R.N., associate director, ECRI Institute PSO, said in a statement. “They are causing harm—often serious harm—to real people.”

 “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. Rather, this list identifies concerns that might be high priorities for other reasons, such as new risks, existing concerns that are changing because of new technology or care delivery models, and persistent issues that need focused attention or pose new opportunities for intervention,” the report authors wrote.

Topping the list this year is information management in EHRs. But the object is still for people to have the information that they need to make the best clinical decision," says Lorraine B. Possanza, program director, Partnership for Health IT Patient Safety, ECRI Institute. "Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible.”

To this end, healthcare organizations must approach health IT safety holistically. According to the ECRI Institute, one key step is integrating health information management professionals, IT professionals and clinical engineers into patient safety, quality and risk management programs. “Other strategies include ensuring that users understand the system’s capabilities and potential problems, encouraging users to report concerns and investigating those concerns, engaging patients in information management and harnessing the power of EHRs to enhance patient safety,” the report authors wrote.

This is the second year in a row that health IT has topped the list of patient safety concerns. Last year, ECRI Institute identified health IT configurations and organization workflow that do not support each other as the No. 1 patient safety concern.

Second on this year’s list is patient deterioration, which can have catastrophic consequences if undetected. Over the past few decades, improved clinical protocols, training and education for providers, and public awareness campaigns have enabled speedier recognition of, and response to, stroke and ST-elevation myocardial infarction (STEMI).

Certain other conditions—including sepsis, some maternal conditions, and serious postsurgical complications—“need the same type of prompt recognition and attention in order for the patient to have a good outcome,” Patricia N. Neumann, R.N., senior patient safety analyst and consultant, ECRI Institute, said in a statement.

"People have seen how well the campaigns have worked for stroke and STEMI and how much they've improved outcomes," Neumann said. "What if those same principles could be applied to other conditions that require fast recognition and management? We could have a big impact on improving outcomes.”

Implementation and use of clinical decision support (CDS) ranked third on this year's list. CDS encompasses "tools that we use to ensure that the right information is presented at the right time within the workflow," Robert C. Giannini, patient safety analyst and consultant, ECRI Institute said. But if implementation or use is suboptimal, opportunities for CDS to aid decision making may be missed. Care could suffer, and patient harm could result, according to the ECRI Institute.

Healthcare organizations must design CDS systems judiciously; resources are available from, ECRI Institute, and others. A multidisciplinary team should have oversight. End users must be trained in the proper use of CDS, as well as their roles and responsibilities, and have access to support structures.

The reminder of the list was as follows:

Test result reporting and follow-up

Antimicrobial stewardship

Patient identification

Opioid administration and monitoring in acute care

Behavioral health issues in non-behavioral-health settings

Management of new oral anticoagulants

Inadequate organization systems or processes to improve safety and quality

As noted above, patient identification once again made the list of top patient safety concerns. According to the ECRI Institute, although the majority of the 7,613 events analyzed for ECRI Institute PSO’s Deep Dive: Patient Identification were caught before they caused patient harm, about 9 percent resulted in patient injury, including two deaths.

“The report brought national attention to an issue that most healthcare providers recognize as a significant problem,” William M. Marella, executive director, PSO operations and analytics, ECRI Institute, said.

Healthcare organization leaders can start to address this problem by fully supporting patient identification initiatives—by prioritizing the issue, engaging clinical and nonclinical staff, and asking staff to identify barriers to safe identification practices, for example.

In addition, the report authors noted that redundant processes for patient identification can increase the likelihood of preventing patient mix-ups. “Elements such as electronic displays and patient identification bands may be standardized. When used as intended, bar-code systems and other technologies can also support safe patient identification,” the report authors wrote.

The list and associated guidance is intended to help healthcare organizations identify priorities and aid them in creating corrective action plans. The ECRI Institute, in the report, also outlined how healthcare organizations can use the list:

Use this list as a starting point for conducting patient safety discussions and setting priorities. The list is not meant to dictate which issues an organization should address. Rather, it’s intended to serve as a catalyst for discussion about the top patient safety issues faced by the organization.

Determine whether your organization faces similar issues that should be targeted for improvement. Organizations can investigate whether they are experiencing problems with these or related concerns—and whether they have processes and systems in place to address them.

Develop strategies to address concerns. The full report on the top 10 patient safety concerns discusses key strategies for each issue, and other ECRI Institute resources provide more in-depth guidance on individual topics.

Consider applications across care settings. Although not all patient safety concerns on this list apply to all healthcare organizations, many are relevant to a range of settings across the continuum of care.

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