ECRI Blog

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. 

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. 

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.

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. 

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.

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. 

​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. 

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: 

A member recently asked about liabilities associated with the utilization of data from nonprescription consumer wearable devices that track various health statuses (e.g., heart rate, blood pressure, activity levels, glucose levels). In our response we discuss the potential risks of utilizing such data and provide information and resources to consider.

The wearable medical device market is rapidly expanding—Deloitte Global predicts that nearly 440 million consumer health and wellness wearable devices will ship worldwide by 2024, and around one-third of individuals own one. However, laws and regulations regarding their use remain unclear. While some physicians support their use as a way to encourage patients to track lifestyle habits that contribute to overall healthcare, others are concerned about associated risks. Many nonprescription commercial wearable devices available to the public are not approved or regulated by the U.S. Food and Drug Administration (FDA), and all have varying degrees of accuracy, usability, privacy protections, and interoperability with existing healthcare technology (e.g., electronic health records, remote patient monitoring systems prescribed by providers). Research on the predictive quality of wearables for health outcomes is also lacking. A 2018 JAMIA literature review found only eight studies of at least moderate quality that supported a significant association between data from wearables and the tracked outcome.

Each year, ECRI publishes a list of top patient safety concerns to call attention to safety risks that need to be addressed to keep patients and staff safe. Concerns on this year’s list are heavily influenced by the top concern on our 2022 list – staffing shortages. Staffing shortages continue to plague healthcare and are contributing to challenges related to the pediatric mental health crisis, violence against healthcare staff, mismatches between assignments and competencies, and missed care treatment.

The number-one concern on this year’s list recognized that children and youth are facing a mental health crisis that has been growing for years. Rates of anxiety and depression in those 17 and younger increased by nearly 30% in 2020 compared with 2016 (American Academy of Pediatrics). The number of emergency department visits for adolescent suicide attempts increased by 39% in winter of 2021 compared with winter 2019, per the Centers for Disease Control and Prevention. 
The topics are selected based on a wide scope of data, including scientific literature, patient safety events or concerns reported to or investigated by ECRI, client research requests and queries, and other internal and external data sources. The top 10 patient safety concerns for 2023 are:

1. The pediatric mental health crisis
2. Physical and verbal violence against healthcare staff
3. Clinician needs in times of uncertainty surrounding maternal-fetal medicine
4. Impact on clinicians expected to work outside their scope of practice and competencies
5. Delayed identification and treatment of sepsis
6. Consequences of poor care coordination for patients with complex medical conditions
7. Risks of not looking beyond the “five rights” to achieve medication safety
8. Medication errors resulting from inaccurate patient medication lists
9. Accidental administration of neuromuscular blocking agents
10. Preventable harm due to omitted care or treatment