A Compendium of Patient Safety Concerns for 2020…and Beyond

According to a March 2020 report by non-profit, independent organization, ECRI Institute, diagnostic errors and maternal health issues are considered to be the top two patient safety concerns for healthcare organizations. This report, however, was released prior to Covid-19 becoming the national focal point in the U.S.

ECRI’s list of the top 10 patient safety concerns was based on analysis of more than 3.2 million patient safety events recorded via the institute’s reporting program.

The list (in order) is as follows:

1. 1. Missed and delayed diagnosis.
   2. Maternal health across the continuum.
   3. Early recognition of behavioral health needs.
   4. Responding to and learning from device problems.
   5. Devise cleaning, disinfection and sterilization.
   6. Standardizing safety across the system.
   7. Patient matching in the Electronic Health Records.
   8. Antimicrobial stewardship.
   9. Overrides of automated dispensing cabinets – This refers to overrides to remove medications from a computerized drug storage device before pharmacists have reviewed and approved the move.
   10. Fragmentation across care settings.

11 Takeaways for the #uniteforsafecare Public Awareness Campaign

The World Health Organization designated September 17 as World Patient Safety Day to raise awareness of healthcare safety and its importance. During that virtual event, the Patient Safety Movement provided 11 takeaways on its Patient Safety Blog for the public, patients and their families to understand while seeking care:

1. 1. Recognize that the system is not perfect.
   2. Stay engaged in your own health care process.
   3. Recognize that your voice matters.
   4. Don’t be intimidated.
   5. Get a second opinion.
   6. Don’t be afraid to “shop around” for healthcare.
   7. Follow your gut.
   8. Double-check everything.
   9. Minority communities must be cognizant of the social disparities in patient care.
   10. Keep in mind that health workers are not to blame, the system is to blame.
   11. Remember that we’re all in this together.

The Joint Commission’s Seven Most Common Sentinel Events

Through the first half of 2020 – ending June 30 – The Joint Commission (TJC) reviewed a total of 437 sentinel events, with 85 percent being voluntarily self-reported by an accredited or certified organization. A sentinel event is a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. That total of 437 is a very low number because it is a grossly underreported by medical organizations. In fact, TJC estimates that only two percent of all sentinel events are reported.

The most common sentinel events for the first six months of this year are as follows:

1. 1. Care management – 165 reported events
   2. Surgical or invasive procedures – 131
   3. Unassigned events at the time of the report – 46
   4. Suicide – 41
   5. Protection events – 38
   6. Environment events – 12
   7. Product or devise – 4

New National Action Plan for Patient Safety

To combat preventable medical harm, the Institute for Healthcare Improvement (IHI) released a National Action Plan on September 17. The report, “Safer Together: A National Action Plan to Advance Patient Safety” was arranged by 27 federal agencies, safety organizations and experts, and patient and family advocates. The plan focuses on four key areas:

1. 1. Culture
   2. Leadership and governance
   3. Workforce safety
   4. Learning systems

Keeping patient safety front and center is critical to force-needed changes within our healthcare environment.

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