ECRI: Pediatric Mental Health Crisis Top Patient Safety Concern of 2023

By Christopher Cheney

ECRI and its affiliate, the Institute for Safe Medication Practices, have identified the Top 10 patient safety concerns of 2023 in a new annual report.

Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

The Top 10 patient safety concerns of 2023 according to ECRI and the Institute for Safe Medication Practices are as follows:

1. Pediatric mental health crisis

Pediatric mental health has reached crisis proportions, Marcus Schabacker, MD, PhD, president and CEO of ECRI, said in a prepared statement. “Even before COVID-19, the impact of social media, gun violence, and other socioeconomic factors were causing elevated rates of depression and anxiety in children. The challenges caused by the pandemic turned a bad situation into a crisis. We’re approaching a national public health emergency.”

Children are now at increased risk for suicide, the new annual report says. “The increase in children experiencing extreme anxiety and depression has led to an increase in suicidal ideation, with more young people age 12 to 25 presenting to the emergency department (ED) for suspected suicide attempts. Although adolescent suicide attempts had decreased during spring 2020, the mean weekly number of ED visits for suspected suicide attempts among those age 12 to 17 was 22% higher in summer 2020 and 39% higher during winter 2021 compared with the corresponding periods in 2019.”

2. Physical and verbal violence against healthcare staff

Only law enforcement and security personnel face more workplace violence than healthcare workers, according to the annual report.

The Joint Commission has made workplace violence against healthcare workers a top priority, the annual report says. “In January 2022, Joint Commission accreditation standards began requiring leadership to develop and enforce a workplace violence prevention program. Joint Commission also states that effective workplace violence programs encourage reporting incidences of threatening language and verbal abuse in addition to physical abuse.”

3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine

When the U.S. Supreme Court overturned Roe v. Wade, which made maternal-fetal medicine a matter of state law, the high court created uncertainty for clinicians and their patients, the annual report says. “Although some states with abortion bans allow abortions to save the life of or prevent harm to the pregnant patient, there is often little guidance on where the line is. If clinicians wait too long, patients may suffer serious harm.”

4. Impact on clinicians expected to work outside their scope of practice and competencies

Healthcare organizations have legal and ethical obligations to make sure clinical staff work within their scope of practice and competencies, but these obligations are being tested in several ways, the annual report says. “Many healthcare workers are still asked to step outside these boundaries, especially during public health emergencies and other societal circumstances such as staff shortages and turnover, increased patient volume, supply chain disruption, and rural facility closings.”

5. Delayed identification and treatment of sepsis

Timely diagnosis and treatment of sepsis, which is the leading cause of death in hospitals, is crucial, the annual report says. “Intravenous antimicrobials should be administered immediately—ideally within an hour of recognition—for patients with shock and possible sepsis and for patients with a high likelihood of sepsis (including those without shock). Antimicrobials should be administered within three hours for patients with possible sepsis without shock.”

6. Consequences of poor care coordination for patients with complex medical conditions

Care coordination is pivotal for patients with complex needs such as multiple chronic conditions because they often face care fragmentation, higher healthcare utilization, and worse health outcomes than other patients, the annual report says. “Improved care coordination can help mitigate these patient safety risks and preventable errors associated with common coordination pitfalls, including interprofessional communication, interoperability of health information technology (IT), medication reconciliation, test tracking and follow-up, and care transitions.”

7. Risks of not looking beyond the “five rights” to achieve medication safety

The “five rights” of medication safety are right patient, right drug, right dose, right route, and right time, but they are insufficient on their own, the annual report says. “Failure to back up the five rights with high-leverage strategies and actionable procedures—or to identify which system processes failed when medication errors occur—undercuts medication safety.”

8. Medication errors resulting from inaccurate patient medication listsInaccurate patient medication lists often occur because a patient is no longer taking a drug or a drug is omitted from the list, and healthcare organizations should have a robust system in place to address the problem, the annual report says. “Multidisciplinary medication reconciliation teams should review current processes, identify gaps and opportunities for improvement, and lead process design and redesign within the healthcare facility or practice. Team members should include executive leadership, physician champions, pharmacists, discharge planners, IT personnel, and patient safety and quality staff.”

9. Accidental administration of neuromuscular blocking agents

Neuromuscular blocking agents paralyze skeletal muscles during mechanical ventilation, and they can be deadly when administered to patients who are not on a ventilator. According to the annual report, there are several causes of accidental administration of these medications, including look-alike packaging, unlabeled and mislabeled syringes, syringe swaps, and residual drug left in intravenous tubing.

10. Preventable harm due to omitted care or treatment

According to the annual report, missed care has several negative consequences, including complications such as pressure injuries, increased length of stay, and decreased patient satisfaction. “Some of the most common predictors of missed care include inadequate staffing levels; increased workload; poor work environment; limited staff experience, education, or competency; lack of material resources; poor communication; poor care transitions; limited skills mix of staff on the unit; and lack of teamwork,” the report says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.