Advancing patient safety awareness by addressing ECRI’s top 10 patient safety concerns

March 14, 2024 |  Patient Safety, Health IT, Patients

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Patient safety has always been at the forefront of MEDITECH's mission. During this year’s Patient Safety Awareness Week (March 10-16), we are celebrating the 10-year anniversary of MEDITECH's internal Patient Safety/Priority Event (PS/PE) Management group. The PS/PE group coordinates initiatives that increase education on patient safety-related topics and workflows. By staying current on patient safety issues that are impacting the industry, healthcare professionals can create safer care environments and reduce the occurrence of preventable Patient Safety Events (PSE).

Key findings from ECRI's 2023 annual list of top patient safety concerns

ECRI annually promotes its Top 10 Patient Safety Concerns. In 2019, they became affiliated with the Institute for Safe Medication Practices (ISMP). ISMP’s Medication Safety newsletters and ECRI’s Top 10 report are important for understanding current patient safety and medication management concerns in the industry. The annual list is based on extensive research and analysis, taking into account factors such as the frequency and severity of incidents, emerging risks, and potential harm to patients.

Here is a full breakdown of the 2023 ECRI Top 10 Patient Safety Concerns

 1. The Pediatric Mental Health Crisis

The COVID-19 pandemic ushered in an unprecedented set of challenges for youth in the United States, contributing to a pre-existing mental health crisis. This emphasizes the importance of focusing on pediatric patients' mental and physical health with tools to collaborate on intervention and support. Learn more about how MEDITECH’s solutions aim to improve behavioral health

2. Physical and Verbal Violence Against Healthcare Staff

Staffing shortages and healthcare workers’ mental health correlate with patient safety concerns. While ECRI often highlights clinical issues caused by device malfunctions or medical errors, researchers are also focusing on concerns such as clinician safety, which were worsened by the COVID-19 pandemic. 

“Shortages in the healthcare workforce and mental health challenges were broadly known and well-documented for years,” said Marcus Schabacker, MD, PhD, president and CEO of ECRI. “Both physicians and nurses were at risk of burnout, emotional exhaustion, and depression prior to 2020, but the pandemic made these issues significantly worse.”

3. Clinician Needs in Times of Uncertainty Surrounding Maternal-Fetal Medicine 

According to the World Health Organization (WHO), almost 800 women died every day in 2020 from preventable causes related to pregnancy and childbirth. To assist in times of uncertainty surrounding maternal-fetal medicine, MEDITECH’s OB Hemorrhage Toolkit supports organizations in the early identification of patients at risk for obstetric hemorrhage by providing optimal workflows, embedded tools, and clinical decision support. Aligned with the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), the Obstetric Hemorrhage Management Toolkit includes an evidence- and experience-based acute content bundle designed to support efforts to reduce maternal mortality.

4. Impact on Clinicians Expected to Work Outside Their Scope of Practice and Competencies 

Nurse practitioners and physician assistants are essential members of the primary care workforce. Non-physician practitioners’ scope of practice is primarily dictated by state laws and regulations. Maintaining knowledge of applicable laws is important to promote communication, ensure patient safety, and decrease potential risk and liability. With reliance on nonphysician practitioners expected to grow in the coming years, this ECRI study provides insight into the scope of practice laws for nurse practitioners and physician assistants. 

5. Delayed Identification and Treatment of Sepsis

MEDITECH’s Expanse Sepsis Management Toolkit is designed to support organizations in the early detection and treatment of sepsis. It is built and maintained in collaboration with customers and staff clinicians and aligns with the recommendations provided by the Surviving Sepsis Campaign (SSC) and the Centers for Medicare and Medicaid Services (CMS) SEP-1 core measure. This toolkit provides evidence-based and outcome-focused implementation guides outlining best practice workflow and system setup recommendations.

6. Consequences of Poor Care Coordination for Patients with Complex Medical Conditions

Children with complex medical conditions are often treated at more than one hospital, making it imperative for clinicians to have access to a summary of care their patients receive from other healthcare organizations. The point-to-point connection provides these standalone children’s hospitals with a consistent approach to accessing and sharing information, making it easier for patients and a summary of their records to move freely between settings. 

Read this success story to learn how Holland Bloorview Kids Rehabilitation Hospital elected to implement a point-to-point interface connecting its MEDITECH EHR with the Epic EHR used by The Hospital for Sick Children (also known as SickKids) and Children’s Hospital of Eastern Ontario. 

7. Risks of Not Looking Beyond the “Five Rights” to Achieve Medication Safety 

Clinical training for nurses often references the ‘Five Rights’ of medication administration: Right Patient, Right Drug, Right Route, Right Time, Right Dose. However, there are concerns about nurses solely relying on the ‘Five Rights’ as it doesn’t fully encompass the patient experience. MEDITECH provides our customers with resources that reinforces the importance of using the medication administration record (MAR) and bedside verification (BMV) to ensure that more than the ‘Five Rights’ are confirmed during administration. 

8. Medication Errors Resulting from Inaccurate Patient Medication Lists

Adhering to ISMP best practices helps safeguard against specific medication safety issues that continue to cause harm. Following MEDITECH’s guidance ensures facilities can focus their medication safety efforts on these best practices that numerous organizations have successfully adopted. Effective November 28, the MEDITECH's Best Practice documentation was updated based on the review of the 2022-2023 ISMP Targeted Medication Safety Best Practices For Hospitals. MEDITECH customers can review the new best practice recommendations to help increase patient safety and reduce medication safety errors.

9. Accidental Administration of Neuromuscular Blocking Agents

Human error has always been a controversial part of patient safety in healthcare. This Nurse Advise ERR story breaks down the topic by delving into a trial that set a dangerous precedent for caretakers. 

10. Preventable Harm Due to Omitted Care or Treatment

With nursing shortages continuing to be a problem since the COVID-19 pandemic, studies show that 55% to 98% of nurses surveyed said they “missed one or more items of required care.” Low nurse staffing levels are directly associated with higher reports of missed care or errors of omission. Read this article to learn more about strategies that can help increase patient safety in nursing.

Playing our part in improving patient safety in healthcare settings 

MEDITECH’s software and clinical decision support tools are designed to ensure patient safety is a top priority. For example, MEDITECH's EHR Patient Safety Review Board provides guidelines, education, and action plans to reduce Patient Safety Events and improve customer satisfaction. To further this initiative, the Customer EHR Patient Safety Advisory Board (CEPSAB) was formed. 

Sponsored by the EHR Patient Safety Review Board, the customer board consists of nurses, pharmacists, physicians, and quality experts. These key players work with MEDITECH’s Implementation, Client Services, and Development Divisions to ensure a timely resolution of priority patient safety issues. The CEPSAB provides guidance to all who develop, implement, and service MEDITECH’s solutions. This interdisciplinary team is dedicated to creating the safest possible use of our EHR solutions across all applications and from all healthcare stakeholder perspectives.

Collaborative efforts to enhance patient safety

Enhancing patient safety requires collaboration and cooperation among all of us in the healthcare industry. Collaborative efforts involve sharing best practices, conducting research and quality improvement projects, participating in patient safety initiatives and campaigns, and fostering partnerships among healthcare organizations, regulatory bodies, and patient advocacy groups.

By working together, these stakeholders can leverage their collective expertise and resources to identify and address patient safety issues, ultimately improving the quality and safety of healthcare delivery. To improve quality and safety, ensure your organization is informed of important Safety Workflow/Education articles and Priority Events by subscribing to the EHR Safety Corner

ECRI has just released their list of Top 10 Patient Safety Concerns for 2024. Stay tuned for MEDITECH recommendations related to these patient safety concerns.

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Written by Nichole Sikora, Senior Manager, Organizational Development, MEDITECH

Nichole Sikora is the Senior Manager of the Patient Safety/Priority Event Management team at MEDITECH. She oversees MEDITECH’s management of Adverse Events, Priority Events, and patient safety initiatives. Nichole also leads the Customer EHR Patient Safety Advisory Board and MEDITECH EHR Patient Safety Review Board. Prior to this role, she was in Client Services management supporting the Pharmacy (PHA) application.