Alarm fatigue, data integrity, patient violence top list of patient safety hazards

The 2015 edition of the ECRI Institute's top 10 patient safety concerns for healthcare organizations includes many of the usual suspects, but also highlights recent headline-grabbing hazards such as patient violence and inadequate reprocessing of endoscopes.

The ECRI report lists alarm hazards as its top concern and data integrity as No. 2, both of which also have held top spots in the nonprofit organization's health technology hazards list in 2013 and 2014. But in its most recent general hazards list, the institute says providers should look beyond the issue of alarm fatigue. "In addition to missed alarms that can result from excessive alarm activations, hospitals also have to be concerned about alarms that don't activate when a patient is in distress," Rob Schluth, senior project officer at ECRI Institute, said in an announcement, adding that this is often due to improperly configured alarm systems.

Patient violence moved up from No. 5 on the 2014 list to No. 3, because "the range and impact of patient violence across the hospital is not limited to incidents that make the headlines," leaving clinical staff to feel abandoned and unable to do their jobs safely, according to the report. Indeed, the issue of healthcare workplace violence has gained significant attention in recent months, even spurring the Occupational Safety and Health Administration to update its guidance to protect healthcare workers from workplace violence.

The inadequate reprocessing of endoscopes also moved up the list in 2015, and though it has made the top 10 health technology hazards for six years in a row, recent events have made the issue more relevant than ever, according to ECRI. The problem stems from the fact that reusable surgical devices often require multiple, difficult steps to clean that leave plenty of room for error. Nowhere was this more apparent than in hospitals that recently reported deadly outbreaks of the superbug carbapenem-resistant Enterobacteriaceae tied to the use of a hard-to-clean device known as a duodenoscope.

Opioid-related events also made the list for the first time in two years, which reflects that fact that prescriptions and use of these powerful painkillers are on the rise, the report states. The issue has led some hospitals to tighten regulations on use of opioids, FierceHealthcare has reported.

Here's a full list of the top 10 patient safety concerns for 2015:

  1. Alarm hazards: inadequate alarm configuration policies and practices
  2. Data integrity: incorrect or missing data in EHRs and other health IT systems
  3. Managing patient violence
  4. Mix-up of IV lines leading to misadministration of drugs and solutions
  5. Care coordination events related to medication reconciliation
  6. Failure to conduct double checks independently
  7. Opioid-related events
  8. Inadequate reprocessing of endoscopes and surgical instruments
  9. Inadequate patient handoffs related to patient transport
  10. Medication errors related to pounds and kilograms

To learn more:
- read the report (.pdf)
- here's the announcement

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