By Christopher Cheney
ECRI released a report today on the Top 10 patient safety concerns of 2022.
ECRI is an independent, nonprofit organization dedicated to improving the safety, quality, and cost-effectiveness of care across all healthcare settings. The organization’s annual Top 10 patient safety list is developed by multidisciplinary staff at ECRI and the organization’s affiliate, the Institute for Safe Medication Practices (ISMP). Patient safety concerns are also validated by scientific literature as well as ECRI and ISMP data such as accident investigations and reported medication safety problems.
The Top 10 patient safety concerns of 2022 are as follows.
1. Workforce shortages: “Even before the COVID-19 pandemic, there was a persistent shortage of clinical and nonclinical staff across the continuum. Staffing shortages have continued to increase throughout the pandemic,” the ECRI report says.
2. Healthcare worker mental health problems linked to COVID-19: “An often discussed but inadequately addressed collateral result of the COVID-19 pandemic is the toll it has taken on the mental health of healthcare workers. Healthcare professionals’ mental health was already at crisis level before the COVID-19 pandemic; both physicians and nurses were at risk of burnout, emotional exhaustion, or depression prior to 2020. The pandemic has now forced a reckoning with healthcare workers’ mental health needs,” the report says.
3. Bias and racism in addressing patient safety: “Racial and ethnic disparities have been well documented in how they affect access to care and outcomes. What is less well publicized is that disparities can even affect how adverse events are reported and responded to. … Although patients from racial and ethnic minority groups are more likely to experience an adverse event while in the hospital, providers are significantly less likely to report harmful events for patients from minority groups than for white patients. In one study, the odds of reporting patient safety events in African American patients were only 0.65 times the odds of reporting in white patients,” the report says.
4. Vaccine coverage gaps and errors: “The success of any vaccine relies on correct, widespread administration to appropriate populations. Vaccine gaps and errors may harm patients or provide inadequate protection against serious diseases,” the report says. The most frequently reported vaccine errors include wrong vaccine, wrong dose, and expired vaccines.
5. Cognitive biases and diagnostic error: “Cognitive biases can result in misdiagnoses by skewing how clinicians gather and interpret evidence, take action, and evaluate decisions,” the report says. For example, anchoring bias occurs when clinicians stick to an initial impression despite the development of conflicting evidence.
6. Nonventilator healthcare-associated pneumonia: “Pneumonia is the most common healthcare-associated infection in the United States and is linked to substantial morbidity and mortality. Despite the attention placed on ventilator-associated pneumonia, nonventilator healthcare-associated pneumonia (NVHAP) diagnoses in the United States make up 65% of the cases, compared with 35% associated with ventilators,” the report says.
7. Human factors in operationalizing telehealth: “Overlooking human factors in the design, implementation, usability, and evaluation of telehealth systems may lead to a situation mirroring what happened during the widespread adoption of electronic health records (EHRs), which caused numerous issues for providers and patients alike, including: fractured adoption, interrupted workflows, user dissatisfaction, [and] complete system failure,” the report says.
8. International supply chain disruptions: “The United States heavily relies on international manufacturers to produce medical equipment, drugs, and other healthcare supplies. While medical supply and drug shortages have long been a problem in healthcare, this issue has been exacerbated by international supply disruptions resulting from the COVID-19 pandemic and other recent natural disasters,” the report says.
9. Products subject to emergency use authorization: “During emergencies, the U.S. Food & Drug Administration (FDA) can issue emergency use authorization (EUA) for drugs, devices, or biologics for serious diseases or conditions when no FDA-approved alternatives are available. However, FDA requires lower levels of evidence of safety and efficacy for EUA issuance than for FDA approval,” the report says. Several EUAs have been issued during the coronavirus pandemic.
10. Telemetry monitoring: “Telemetry monitoring (TM) provides real-time measurements of monitored physiologic parameters from a distance. Technological breakdowns as well as breakdowns related to clinician response increase the risk of patient harm by the disruption in identification of critical and abnormal changes in a patient’s health status,” the report says. Common problems with telemetry monitoring include alarm fatigue, equipment not connected as ordered, patient connected to the wrong equipment, and equipment malfunctions.
Christopher Cheney is the senior clinical care editor at HealthLeaders.