Since 2009, the ECRI institute has released an annual report identifying the top 10 patient safety issues based on approximately 2 million event reports, expert analyses, and other factors. While not comprehensive of all current patient safety issues, the list is meant to be used as a starting point for discussions and priority setting.
Upon reviewing the 2018 list, missing or incorrect information is a factor for all the issues highlighted. In this two-part column, I will briefly discuss how this lack of information or miscommunication contributes to these patient safety issues.
1. Diagnostic Errors
According to John Hopkins researchers, “…diagnostic errors — not surgical mistakes or medication overdoses — accounted for the largest fraction of claims, the most severe patient harm, and the highest total of [malpractice claim] payouts. Diagnosis-related payments amounted to $38.8 billion between 1986 and 2010.” This is staggering, considering that most diagnostic errors are preventable, and these missed, delayed, or incorrect diagnoses can be significantly reduced with additional information or testing.
Like so many preventable errors, diagnosis errors are primarily caused by poor communication and care coordination. Many IT solutions exist to help piece together a whole picture of a patient’s medical history, but current information is often delayed and not available at the point of care, leaving clinicians to diagnosis without all the data necessary.
2. Opioid Safety Across the Continuum of Care
There is certainly no lack of awareness when it comes to the opioid crisis in the United States. According to the Centers for Disease Control and Prevention, more than 115 people in the United States die every day due to opioid-related overdoses as of March 2018 and prescription opioid misuse alone costs the United States $78.5 billion a year.
There have been great strides in monitoring opioid prescription behavior to reduce misuse, but one issue that has not received the attention it deserves is what other medications patients are taking in addition to opioids. The combination of benzodiazepines, muscle relaxants, and opioids, for example, severely increase the risk of respiratory failure. This issue is exacerbated by the fact that drug prescribing activity is typically only tracked within the prescriber’s institution, causing blind spots when drugs are prescribed elsewhere. For example, if a muscle relaxant is filled at Pharmacy A, the pharmacy has no way of knowing if a patient filled an opioid prescription at Pharmacy B. It’s not surprising that these two are available concomitantly to a patient posing substantial risk to patient safety.
3. Internal Care Coordination
Care coordination is vital to every aspect of patient care and certainly cannot be covered in its entirety in this short post, so I’d like to focus specifically on one element of it: hand-offs. Even in today’s world inundated with digital technology, there are many instances where patient information is written on a slip of paper and handed to a provider during a care transition. As you can imagine, this opens patient care up to countless human and communication errors. It’s like a game of telephone: As patient information is passed from one provider to the next, the original information is bound to become less complete and accurate.
It would seem that the use of healthcare IT is a surefire way to improve care coordination. While many EMRs include tools that address this exact issue, tools are only as good as the people using them. Organizations need to make documentation of patient information in a digital, legible format an integral part of their process. This will help ensure the most complete and accurate patient record is available to any provider throughout the continuum of care.
ECRI says that workarounds occur in healthcare “…when staff bend work rules to circumvent or temporarily fix a real or perceived barrier or system flaw.” In my experience, workarounds arise when policies and procedures are not properly defined and/or communicated. When caregivers do not know what is expected of them, they will do whatever is necessary to complete their tasks.
In his book The Checklist Manifesto, Atul Gawande discusses how most errors in the modern world are caused by errors of ineptitude, or in his words: “…mistakes we made because we don’t make proper use of what we know”. So, mistakes happen not because our caregivers are incompetent, but rather they are not provided with proper guidelines to make sure all necessary steps are taken. Healthcare organizations should take the time to develop checklists for as many care protocols as possible and institute a culture in which protocols must be followed consistently.
5. Incorporating Health IT into Patient Safety Programs
Health IT was intended to reduce errors and improve patient care and safety; however, it often falls well short of these grand aspirations. IT shortcomings can be caused by a variety of issues, from poor implementation to insufficient training, but the root of all issues would seem to come from a lack of communication.
As noted on in other sections of this column, IT tools are only as good as the people using them. Clear safety guidelines and procedures need to be implemented so clinicians know what is expected of them when it comes to documenting patient data in IT solutions.
I would also add that strong communication needs to exist between organizations and their IT vendors. Frequent testing, with a focus on patient safety, must take place throughout the design, development, implementation, and use of any healthcare IT solutions an organization chooses to use. It is also worthwhile to have clinical end-users heavily involved in the implementation of IT solutions.
For further information, I suggest reading "Improving Patient Care Through Safe Health IT."