Four of the top 10 patient safety concerns, compiled from reports of more than 1.2 million safety events, literature review and expert opinion, have relevance for laboratories and diagnostics. ECRI Institute’s third annual Top 10 Patient Safety Concerns for Healthcare Organizations 2016 includes “real things that are happening,” stated Associate Director for the ECRI Institute PSO, Catherine Pusey, RN, MBA, in the executive summary. They aren’t the most frequently cited or the most severe issues, added Bill Marella, MBA, MMI, ECRI’s executive director, PSO operations and analytics. “We’re trying to pick out the things that are relatively novel or that are not necessarily new but are manifesting themselves in a new way because of changes in the healthcare system.”
Labs will find most relevant the safety issue appearing at number five on ECRI’s list: Inadequate Test-Result Reporting and Follow-up. Factors that affect test reporting safety issues included inadequate communication among providers and failure to follow up with and by patients on test results and their health implications.
There are several other items that are also of relevance to laboratories on the list. The number one safety concern cited was “Health IT configurations and organizational workflows that do not support each other”—meaning that operationally, people don’t adjust to new IT systems. This disconnect affects communication and prevents up-todate sharing of information about patients including, for example, lab test results. This is an issue very relevant to laboratories who utilize IT systems to communicate with referring providers regarding test orders and test results.
The second item on the list is patient identification errors—which ECRI notes have “broad implications” and “serious consequences.” G2 Compliance Advisor (GCA) has previously highlighted the importance of the lab’s role in patient identification (see GCA, March, 2016, p. 3). Tejal Gandhi, M.D., president and CEO of the National Patient Safety Foundation (NPSF) told sister publication National Intelligence Report that labs need to look at internal processes that could lead to a potential breakdown in patient identification. For example, they need to consider how certain they are that results are received by providers and identify communication gaps so they can make processes more reliable. Additionally, the College of Healthcare Information Management Executives (CHIME) has launched a National Patient ID Challenge to find solutions to patient identification errors. CHIME pointed out that the error rate in matching patients to their records is usually 10 to 20% within a healthcare system and can rise to 50 to 60% when organizations exchange data through the care continuum.
Two issues at the bottom of the top 10 should resonate for labs as well: inadequate antimicrobial stewardship (ninth on the list of top 10 safety issues) and failure to embrace a culture of safety (10th). Antibiotic resistance is a national concern receiving not just media attention but significant federal funding. ECRI’s report raises the alarm stating “Action is needed now to avoid an antibiotic apocalypse,” added Sharon Bradley, RN, CIC, ECRI Institute’s senior infection prevention analyst, in ECRI’s executive summary. Diagnostics play a key role in the fight against antibiotic resistance. In fact, the federal government’s Combating Antibiotic-Resistant Bacteria (CARB) National Action Plan includes efforts to “advance the development of diagnostics to detect antimicrobial resistance.”
Finally, all health care organizations including laboratories, should be concerned about a culture of safety. “[E]mbracing a culture of safety is the foundation for mitigating any of the concerns on the Top 10 list,” according to ECRI Institute patient safety analyst and consultant, Mary Beth Mitchell, MSN, RN, CPHQ, CCM, SSBB, who also advised in the report that leadership must set the tone by publicly embracing patient safety.
Takeaway: Laboratories need to consider top patient safety concerns for health care organizations and how they can contribute to solving these safety issues.