ECRI Blog

ECRI’s Top 10 Patient Safety Concerns for 2024

ECRI recently published our Top 10 Patient Safety Concerns for 2024 Special Report—the annual guide that calls attention to pressing patient safety concerns facing the healthcare industry.

For this report, we draw on evidence-based research, data, and expert insights from ECRI and the Institute for Safe Medication Practices (ISMP). But we do more than highlight where concerns exist; we also provide encouragement and education to support organizations in addressing them with a Total Systems Safety approach. 

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Topics: Patient Safety

IWD 2024: How to Continue Progress in Cervical Cancer Screening

International Women’s Day is an opportune time to celebrate improvements in women’s health outcomes—and reflect on steps we can take to achieve even more progress. For this blog, we’re focusing on a specific women’s health issue: cervical cancer. 

Years ago, this form of cancer was one of the most common causes of cancer deaths among women in the U.S. But between 1955 and 1992, the incidence and death rates declined by more than 60%. Credit goes to the development of the Papanicolaou test—commonly known as the Pap smear or Pap test.

One of the most effective cancer screening tests available, the Pap smear helps clinicians identify cervical intraepithelial neoplasia (CIN) and remove it before it progresses to cervical cancer. The test also enables detection of cervical cancer at an early stage.

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Topics: Patient Safety

15 Years as a PSO. Decades Improving Safety.

This year, ECRI and the Institute for Safe Medication Practices PSO celebrates our 15th anniversary as an AHRQ-listed Patient Safety Organization. Over this decade and a half, we have worked tirelessly to build and maintain the trust and reputation that confirms ECRI and ISMP’s deep roots in safety . In our 15 years as a PSO, we have collected close to 6.5 million safety events, including over 4.4 million adverse events (events that reached the patient and caused a degree of harm), 880,000 near misses (an adverse event was averted), and 1.2 million reports of unsafe conditions (events that could have led to patient harm). Behind those numbers are the stories of people: moms and dads, sons and daughters, friends and neighbors, who have been unintentionally harmed in our health systems. However, there are also stories of brave healthcare team members who recognized the risk for harm and had the courage to speak up for safety, intervene, and catch that near miss before the patient was harmed. With our immense database of safety events comes a great responsibility to learn from these stories and understand the failures in our healthcare systems that lead to harm.  The learning and action that result from these events is how we will demonstrate our constancy of purpose for improving patient safety. 

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Topics: Patient Safety

10 Steps to Preventing Patient Elopement

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. 

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Topics: Patient Safety

Video Recordings of Surgical Procedures: How to Ensure Consent, Privacy, and Confidentiality

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. 

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Topics: Patient Safety

Medical Errors and Health IT: What Does the Data Say?

Health information technology (IT) is a powerful tool for documenting and sharing information about patients’ health and helping providers to make well-informed decisions about patient care. However, problems relating to health IT, including both system and user issues, are also sometimes cited as factors in causing or contributing to patient harm—and even lawsuits.

Patient Safety

Problems related to health IT can cause patient harm, including serious harm or death. A 2017 systematic review of health IT problems and their effect on patient outcomes and care delivery found that health IT problems were associated with patient harm and death in 53% of the studies reviewed. Use errors and poor user interfaces impeded the receipt of information and led to errors of commission in decision-making. Problems with system functionality (including poor user interfaces and fragmented displays), system access, system configuration, and software updates caused delays in care delivery. Several studies characterized medication errors related to health IT problems in more detail.

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Topics: Patient Safety

Non-medical Discharge: Navigating Legal, Regulatory, and Ethical Considerations

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. 

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Topics: Patient Safety

Supporting Women Veterans: The Role of Healthcare Leaders

On June 12, we recognize Women Veterans Recognition Day, a date designated to mark the anniversary of the signing of the 1948 Women's Armed Services Integration Act, which allowed women the right to permanently serve in the regular armed forces. The Act, along with President Truman’s decision to desegregate the military, also permitted African American women to officially serve in the military. The date is recognized nationally and by a number of states.
As a mission-driven organization, ECRI’s vision is a world where safe, high-quality healthcare is accessible to everyone, including our nation’s women veterans and service members. ECRI is proud to have women veterans as part of our workforce, working hard each day to advance our mission. Our nation’s women veterans face unique physical and mental health needs. Many bear the scars of combat, both those you can see and those you cannot. To effectively support their needs, healthcare leaders need to address gaps in the current systems that fail these veterans.

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Topics: Patient Safety

Evidence-based Strategies for Preventing CAUTIs from Indwelling Catheters

According to the Centers for Disease Control and Prevention (CDC), urinary tract infections (UTIs) are the most common healthcare-associated infection, and approximately 75% of UTIs acquired in the hospital are catheter-associated urinary tract infections (CAUTIs). 

Urinary catheters interfere with the natural host defense of clearing the bladder and urethral mucosa of microbes through voiding. The catheter also acts as a direct entry portal into the bladder for nearby microorganisms. Pathogens can access the urinary tract either from outside the catheter or from a contaminated collection bag or catheter-drainage tube connection. Many bacterial species colonize indwelling catheters as a thin, slimy film that adheres to a surface. In this form, bacteria are resistant to antibiotics and host defenses. 

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Topics: Patient Safety

Navigating the Death of a Pediatric Patient

An ECRI member recently asked for information regarding support for healthcare providers navigating the death of a pediatric patient. In our response, we discuss strategies and provide relevant resources for healthcare staff confronted with the death of a child. 

Although patients and their families are obviously at the center of adverse patient safety events, a ripple effect often occurs, turning the involved healthcare providers into "second victims," who may require or benefit from organizational support. A survey of over 100 healthcare professionals regarding their grief after the death of a child found that the majority of second victims turned to others to talk about the child and their emotions (85%), used positive reframing (80%), sought emotional support (75%) or self-distraction (57%). Other strategies included seeking religious guidance (55%), meeting with the patient's parents (43%), and attending the patient's funeral (19%). More than half (53%) believed that turning to coworkers, friends, or family helped them the most to overcome their grief. The second most useful strategy was spending time alone (19%). However, 31% wished they had more emotional support from their colleagues, and while 8% received organized support from their workplace, 40% would have appreciated more "official" support. 

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Topics: Patient Safety

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