ECRI Institute’s second annual list of the top 10 patient safety concerns for healthcare organizations includes inadequate reprocessing of endoscopes and surgical instruments.
“This is more than just a list; it’s a reminder that, despite the attention given to patient safety over the last 15 years or so, we can do better,” stated William Marella, MBA, executive director of operations and analytics at the ECRI Institute Patient Safety Organization (PSO) in Plymouth Meeting, PA. “Healthcare providers, regardless of what setting they practice in, can start with our top 10 list of patient safety concerns and use it to guide their own discussions about patient safety and improvement initiatives.”
This year’s list includes:
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alarm hazards: inadequate alarm configuration policies and practices;
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data integrity: incorrect or missing data in EHRs and other health IT systems;
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managing patient violence;
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mix-up of IV lines leading to misadministration of drugs and solutions;
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care coordination events related to medication reconciliation;
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failure to conduct independent double checks in a way that is truly independent (a second provider fails to check the work totally independent of what that provider is being told, free from the potential for confirmation bias);
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opioid-related events;
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inadequate reprocessing of endoscopes and surgical instruments;
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inadequate patient handoffs related to patient transport;
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medication errors related to pounds and kilograms.
To compile its list of patient safety concerns, the ECRI Institute PSO reviewed its database of patient safety events, root-cause analyses, and custom research requests submitted by healthcare organizations and its partner PSOs, and it also sought guidance from its staff.
Topping the list is alarm hazards from inadequate configuration policies and practices. ECRI Institute encourages healthcare institutions to look beyond alarm fatigue. Rob Schluth, senior project officer at ECRI Institute, said, “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. In our experience, alarm?related adverse events — whether they result from missed alarms or from unrecognized alarm conditions — often can be traced to alarm systems that were not configured appropriately.”
The number 8 concern is “inadequate reprocessing of endoscopes and surgical instruments.” On April 3, the Centers for Medicare and Medicaid Services (CMS) issued a memo to its state surveyors to address concerns from the agency’s leaders regarding outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) during gastrointestinal endoscopy, particularly endoscopic retrograde cholangiopancreatography (ERCP). The memo points out that duodenoscopes used to perform ERCP are difficult to clean and disinfect, even when manufacturer reprocessing instructions are followed correctly, and they have been implicated in these outbreaks. The Food and Drug Administration has issued a Safety Communication warning, with related updates, that the design of duodenoscopes might impede effective cleaning.
CMS says hospitals, critical access hospitals (CAHs), and ambulatory surgical centers “are expected to meticulously follow the manufacturer’s instructions for reprocessing duodenoscopes, as well as adhere to the nationally recognized multisociety consensus guidelines developed by multiple expert organizations and issued in 2011.” (For more information on duodenoscopes, see the May 2015 Same-Day Surgery.)
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