ECRI Blog

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.