A disconnect between health IT configurations and organizational workflow topped the ECRI Institute's 2016 list of top 10 patient safety concerns.
When a health IT system is implemented, organizations need to tailor the configuration to the workflow and vice versa, but this often doesn't happen. When health IT configuration and workflow clash, communication suffers, the organization says in an announcement.
In its third annual list, the institute focused on concerns that are happening, but not necessarily those that are most frequent or severe. "We're trying to pick out the things that are relatively novel or that are not necessarily new but are manifesting themselves in a new way because of changes in the healthcare system," executive director Bill Marella says.
Patient identification errors ranked No. 2, a problem that has prompted the College of Healthcare Information Management Executives to launch a $1 million challenge to entrepreneurs to create a more effective and secure patient ID system.
While last year's list included many of the usual suspects, it called attention to patient violence and inadequate reprocessing of endoscopes.
Though opioid events were mentioned last year, this year it's more specific: inadequate monitoring for respiratory depression in patients prescribed opioids. It recommends a nurse-driven protocol to determine whether a patient is merely sleeping or overly sedated.
It also cites inadequate test-result reporting and follow-up, as well as medication errors related to pounds and kilograms. It rounds out the list with No. 10: failure to embrace a culture of safety.
To learn more:
- here's the announcement
- download the report