ECRI Blog

Regardless of the type of healthcare facility you manage—a hospital, an assisted living center, or an ambulatory care establishment—incident management for patient safety should be a primary focus of your organization. By taking time to assess patient safety, produce incident reports when accidents or infections occur, and understand the causes of various accidents, you can offer a better quality of care over time. That being said, it's important to know what you can gain by finding the proper incident reporting and management system for your organization. If you want to provide better healthcare for your patients and support risk managers, clinicians, and other healthcare professionals, consider the many benefits of an effective incident management system.

1. It allows you to identify trends in common medical errors

There are certain accidents that might only occur once, becoming an outlier in your organization's medical history; however, it's more common for specific types of incidents to occur repeatedly. An effective incident management system allows you to identify trends in common medical errors as your staff inputs incident reports. Whether you encounter medication safety issues, healthcare-associated infections, or even safety issues such as frequent falls among older adults, incident reporting and management can help you identify these trends so that you can take action.

Accidents, outbreaks, and other incidents regularly occur in healthcare settings. This is not surprising to most healthcare providers, including those working in aging services and ambulatory care facilities.

But acknowledging that incidents will happen can be the impetus behind taking precautions to prevent them. With effective incident management systems and protocols in place, your team can create a culture of safety and security that helps protects patient and staff health, as well as your institution’s reputation and financial stability.

But what does a good incident management system look like? How can you improve your system, and where can you get fact-based, reliable support that will help your team build a better incident prevention and management system?

The COVID-19 pandemic has focused attention on healthcare emergency preparedness and response demonstrating real-time, the correlation between emergency preparedness and the safety and quality of care and services. But emergency preparedness did not begin with the pandemic—nor do the lessons stop there. The pandemic provided sobering evidence that these correlations exist beyond acute care, as demonstrated in other settings such as ambulatory and especially aging care.

Other highly-disruptive forces have increased the urgency for more robust emergency planning and response across the all care settings. An increasing frequency of threats from potentially life-threatening emergencies such as hurricanes, tornados, wildfires, severe flooding, and even cyberattacks now need consideration in every provider organization’s emergency preparedness and response efforts.

Any of these emergencies and related hazards require organizations to move from routine to non-routine operating environments. The ensuing disruption of continuity of care and services leads to a myriad of risks and opportunities for harm.

A critical area of operations which is often overlooked until an emergency occurs is purchasing and supply chain management—and when an emergency occurs it’s too late to effectively respond. Not having the right types and amounts of medications, supplies, and equipment available when needed creates real harm for not only persons served, but also the workforce who shoulders the burden of delivering the care and services throughout an emergency. Additionally, these risks extend enterprisewide, opening up an organization to real financial and reputational harm.

"Communication failures cost 1.5 times as much as claims without communication failures, and were more than twice as likely to result in a payout of more than $1 million," the Journal of Patient Safety study noted.

Roughly 20,000 malpractice claims are filed annually in the U.S. alone, and half of all physicians will be sued sometime during the course of a career. During the pandemic, lower numbers of claims were reported from some institutions, but others, such as those in aging services, continue to face this challenge without relief. And even with some reduction in occurrences, malpractice insurance rates continue to rise. Most importantly, claims are tied to patient care and safety, the metric most important to those who work tirelessly to provide care during what is now the third trying year of this pandemic.

Newly published information reveals ineffective and non-existent communication as significant threats to patient safety. You might ask, “How can communication be such a problem when we work closely together, huddle, and meet often?” It’s a oversimplified example, but we all remember the childhood game of “whisper down the lane,” where the original message never matched the message received by the last person in the line.” Communication can be incomplete, misinterpreted, or flat-out incorrect. The good news is, there are ways to improve communications and subsequently improve patient safety and reduce medical malpractice claims.

All who have cared for our nation’s older adults through the COVID-19 pandemic have given so much; the toll in lives lost, illness, and financial and economic impacts have been great for those we serve, all aspects of the workforce, and provider organizations alike. But the care-critical work is not over.

As the COVID-19 pandemic response and recovery efforts continue worldwide, in our nation, and specifically in the aging services sector it is more important than ever that providers continue efforts to prevent harm to residents, staff, and healthcare partners who care for older adults, and their families and loved ones.

Data from Pennsylvania’s COVID-19 Vaccine Needs Assessment Survey, as shared by the Pennsylvania Department of Health on April 1, 2021, indicates the same trends that other U.S. studies also suggest: a statistically significant lag in COVID-19 vaccination acceptance rates in staff and contractors working in the aging services sector compared to the vaccination acceptance rates of the residents they serve and care for.

With several vaccines against COVID-19 already available through emergency use authorization (EUA), others potentially on the way, and a nationwide vaccination campaign to administer the vaccine to as many people as quickly possible, the COVID-19 pandemic continues to transition to new phases. And yet with new hope comes new challenges and emerging risks as organizations work to safely care for older adults.

According to the Centers for Disease Control and Prevention (CDC), skilled nursing facilities that conducted at least one vaccine clinic during the first month of roll-out administered a first shot to a median of 77.8% of their residents and 37.5% of their staff. As the agency points out, the moderately high coverage among residents is counterbalanced by relatively low coverage among staff.

Healthcare workers face work-related risks, illnesses, and injuries, and patient safety is directly tied to worker safety. Creating a culture of safety is crucial.

ECRI, and its affiliate, the Institute for Safe Medication Practices (ISMP), proudly joined global leaders in supporting World Patient Safety Day 2020, held September 17. Now in its second year, World Patient Safety Day was founded by the World Health Organization (WHO) to recognize patient safety as a global health priority. At its inception, all 194 WHO Member States endorsed the establishment of the day with the objectives of increasing public awareness and engagement, enhancing global understanding, and spurring global solidarity and action to promote patient safety.

The stakes are high in medicine and healthcare – they pertain to life and death, as the current pandemic has reminded us on an hourly basis. This is especially true when it comes to those who care for our older adults, given their high vulnerability to COVID-19. For many older adults, this illness has proven deadly.

Rightfully, given the potential for harm, aging services providers are held to high standards and expectations. We are taught to focus on what went wrong and fix it; every aspect of quality assurance in our industry is built on a platform that looks for “deficiencies” in care and service delivery, investigates them, and demands correction. Yet that is only part of an effective process that builds communities conducive to providing quality care that promotes health and well-being.

Decisions made and actions taken in the first minutes and hours after an incident occurs in an aging services organization set the stage for everything else that follows. For instance, consider this hypothetical scenario:

A resident falls out of a lift, breaking a hip, but it is unclear what caused the fall. The lift is briefly checked by the staff involved, and they see nothing wrong, so the lift is not removed from service while the incident is investigated further. The next day, another resident falls from the same lift in a similar manner.

In the United States, there are 30 times more outpatient visits as hospital discharges. As a result of the high volumes and complexities inherent to ambulatory settings, one in twenty patients can expect to experience a diagnostic error in their lifetime. According to the Agency for Healthcare Research and Quality, 55 percent of patients said that diagnostic errors were a chief concern to them. 

Earlier this fall, ECRI Institute Patient Safety Organization took an in-depth look at patient safety events in ambulatory care, specifically physician practices and healthcare clinics. Nearly half of the 4,355 analyzed events were related to diagnostic testing. Errors that occur during diagnostic testing can have potentially devastating consequences for patients. The majority of these events occurred after tests had taken place, often due to a gap in communication.