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Patient Safety Risks for 2020

photo caution signs in pile - dangerous patient safety risks Everyone needs medical care at some point in their lives. And no one wants to be harmed by their healthcare. So, on the heels of Patient Safety Awareness Week, it’s a good time to consider common, dangerous patient safety risks. Of course, you can’t consider patient safety without mentioning the COVID-19 pandemic – a top health concern for people all over the world. However, today’s post focuses on the top 10 patient safety concerns identified by ECRI. This recently published list, put together before the COVID-19 outbreak, identifies risks compiled from 3.2 million reports of healthcare events that caused patient harm.

Today’s blog post covers the first 5 safety risks. Watch out for next week’s post for the final 5 risks.

1. Missed and Delayed Diagnoses.

When doctors miss a diagnosis, or delay a diagnosis, patients may not get needed treatments in a timely manner. Without treatment, conditions can worsen, which can increase suffering and lead to worse outcomes, including permanent damage or death.

How common are diagnostic errors?

An estimated 12 million Americans experience a diagnostic error in the primary care setting each year. Moreover, researchers report that diagnostic errors that may have contributed to death were found in 10% of autopsies.

Why do doctors make diagnostic mistakes?

photo old woman talking to doctor - dangerous patient safety risksIn order to correctly diagnosis a patient, the doctor must understand each patient’s relevant circumstances. Doctors need an accurate history and should perform an appropriate physical examination. However, all of this takes time, something often in short supply in time-squeezed appointments. And it’s important to understand that medicine is part science, part art.

What can improve the diagnosis process?

Electronic health records (EHRs) can help if they allow doctors and other clinicians to easily see the full scope of the patient’s history, conditions, tests, prior diagnoses, medications, etc. Additionally, ECRI recommends that each organization’s culture support open discussion of the diagnostic process as well as learning from diagnostic mistakes. Finally, ECRI suggests that doctors and other clinicians talk through cases and the diagnostic process with other doctors, including those from different areas of expertise.

What can you do?

To reduce your risk of diagnostic errors, read my blog posts:

2. Maternal health issues.

photo pregnant woman - patient safety risksAll pregnant woman want a safe pregnancy and a healthy baby. Unfortunately, pregnancy can be dangerous for mothers and can sometimes lead to maternal death. The care women receive before, during and up to one year after childbirth impacts their safety and health. Interestingly, about 2/3 of “pregnancy-related deaths occur in the postpartum period, with one-third concentrated in the later postpartum phase (one week to one year after delivery).”

How serious are maternal health issues?

According to the Centers for Disease Control and Prevention, in the US, 700+ women die each year from childbirth-related complications. Moreover, about 60% of these deaths are considered preventable. Unfortunately, the maternal death rate in the US is the highest among the world’s developing nations, and it’s rising.

Why?

There are many factors influencing maternal health in the US, including:

  • Racial and ethnic disparities
  • Care coordination among all care providers
  • Provider-patient communication
  • Patient engagement
  • Risk factors such as pregnancies in older women
  • Access to quality care
How can maternal care improve?

ECRI suggests that providers use tools and technologies, as well as knowledge of best care practices, to identify risk factors and adjust treatment plans accordingly. Additionally, obstetric practices should form collaborative partnerships with pregnant women, their families (or other supporters), and with other healthcare and social service providers.

What can you do?

It’s a given that pregnant women need access to high-quality care. But, even with the best care by the best doctors, it’s important for pregnant women to engage fully in the healthcare process, similar to dealing with any other kind of medical condition. For tips on getting better care, read these blog posts:

3. Early recognition of behavioral health needs in healthcare settings.

Healthcare workers face more violence than those in any other industry. Why? Patients may be in unfamiliar situations and/or may be off balance.

What should healthcare organizations do?

Doctors and other clinicians should recognize and respond to patients’ behavioral quickly and efficiently. Therefore, organizations should train staff not to label or judge patients, and to recognize when patient behavior may be escalating. Educational efforts should also focus on how to destigmatize an aggressive patient, including the importance of listening and apologizing when necessary.

Additionally, patients should undergo behavioral assessments as needed. And, rapid response teams should conduct drills to improve their response times.

Finally, the ECRI report states that providers must realize that patients who act aggressively may not have a mental illness. In fact, only 3% to 5% of violent acts are committed by an individual with a serious mental illness.

4. Responding to and learning from medical device problems.

photo surgical toolsMedical devices help patients survive and thrive. But they can also cause harm when they fail. Although patient health must be the primary concern after a medical device problem, organizations must properly investigate each incident. Every organization should have protocols for investigating incidents involving specific types of devices, equipment, or disposables, with a goal of gathering useful information, learning from it, and preventing recurrence.

How often do medical devices cause harm?

Researchers found that medical devices caused patient harm in 84 of every 1,000 admissions in one hospital.

What can you do?

Read my blog post How Safe are Medical Devices?

5. Device cleaning, disinfection and sterilization.

When patients come in contact with contaminated devices, tools and other items, they can be exposed to dangerous germs. The sterile processing departments (SPDs) must clean, decontaminate, inspect, assemble, package, store, and distribute instruments, equipment and supplies. But, it’s not an easy job – employees must strictly follow processes, with no mistakes.

What makes it hard to sterilize devices properly?

Although proper cleaning, disinfection and sterilization of items can significantly reduce the risk of dangerous germs, not all medical (and dental) offices follow proper procedures. Why? There are several things that can make it hard for employees in SPDs to maintain cleanliness standards, including:

  • Productivity pressures
  • Lack of access to current manufacturer instructions for use and processing technologies
  • Lack of needed supplies
  • Communication breakdowns between SPD staff and the departments they support
  • Lack of universal training and certification requirements
What’s the impact of failure to properly sterilize devices?

Improperly cleaned devices and instruments can lead to serious patient harm, including death. Additionally, failures can damage reputations, bring citations and fines from regulatory bodies, prompt review by accrediting agencies, and lawsuits.

For example, sterile processing failures can lead to surgical site infections, which have a 3% mortality rate and with an estimated annual cost of $3.3 billion.

What can healthcare organizations do?

ECRI recommends “facilities establish effective workflows that involve SPD and clinical staff input, incorporate quality checks throughout the sterilization process, improve interprofessional relationships, and provide continuing education opportunities for staff.” Additionally, they recommend establishing relationships with manufacturers and professional organizations to help develop “policies and procedures to ensure timely and safe turnaround times, reduce preventable errors and associated costs, and ensure patient safety and satisfaction.”

What can you do?

Read my blog post How Safe are Medical Devices?

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