ECRI Blog

​​​​​​​​Vaccinations are an important tool for building immunity to prevent illness, disability, and death resulting from infectious diseases. According to the Centers for Disease Control and Prevention (CDC), 4 million deaths worldwide are prevented by childhood vaccination each year.

As with any medication, errors can occur during the prescribing, preparation, handling, storage, or administration of vaccines. Vaccination errors can affect not only the patient receiving the vaccine but also others who are exposed to the patient if infectious diseases reemerge.

Patient elopement is when individuals leave an area they are expected to stay within, for their safety. Elopement from a healthcare facility can have devastating consequences for a patient, including serious injury or death. 

Oftentimes, resources on elopement are specific to the aging services setting since most elopements occur among older adults who have been diagnosed with Alzheimer's disease or dementia; however, elopement can present a risk for all manner of patients, particularly behavioral health patients and patients with altered mental status. 

In recent years, more OB units in rural areas have experienced closures and maternity care deserts have grown. In response, many rural healthcare organizations are exploring creative approaches in their efforts to maintain OB and gynecology (OB/GYN) services for their patients. The National Rural Health Association describes some of the approaches hospitals and policy makers have taken to try to maintain OB services, such as addressing costs of maternity care, increasing staffing levels, and consolidating health systems.

Combining units and going "on diversion" may also be considered creative approaches to addressing staffing issues in OB units, but such efforts raise potential risks.

Many organizations record surgical procedures performed at their facilities with the intention of using the footage for educational or quality assurance purposes, among other reasons. However, it is important to ensure that such recordings and photographs adhere to the organization's policies regarding patient consent, privacy, and confidentiality, as well as medical record documentation and storage. Because the circumstances may vary, risk managers should carefully consider whether requirements for obtaining a patient's authorization for the use and disclosure of protected health information (PHI) are being met. 

Hospitals may wish to discharge patients for a variety of non-medical reasons (e.g., if the patient is being violent towards staff, patients, or visitors; if the patient is exhibiting racist behavior). However, administrative discharge of patients for non-medical reasons is a more complicated legal and regulatory issue for hospitals than it is for physician practices who wish to terminate a relationship with a patient. 

In the modern healthcare environment, healthcare workers often experience job-related fatigue, which can have a negative effect on patient and staff safety and well-being. In addition, worker fatigue is associated with lost workdays, an increase in occupational injuries (e.g., needlesticks), liability issues, and increased turnover. 

Healthcare organizations must address the effects of fatigue on healthcare workers and, whenever possible, reduce duty hours to allow workers more recovery time. However, even the best schedules and optimal staffing cannot eliminate the circadian disruption associated with night work and long hours. Healthcare organizations should implement fatigue management strategies as part of their system-wide efforts to increase patient safety and reduce medical errors. A good fatigue management plan should address the following: 

• Education and training on the effects of fatigue 
• Strategies to increase alertness and mitigate fatigue 
• Opportunities to identify and treat any medical conditions that may affect alertness or fatigue, such as sleep disorders 
• Scheduling policies 
• Adverse event, medical error, and occupational injury investigations 

Healthcare organizations may also wish to consider developing a fatigue risk management system—data-driven sets of management practices for identifying and managing fatigue-related safety risks—as a subset of their overall safety management system. ​ 

Additional resources that may be helpful include the following: