Know Your Enemy

Combatting The Top 10 Patient Safety Concerns

By Sue Sgambati, MD

Each year, the Emergency Care Research Institute issues its Top 10 Health Patient Safety Concerns. This identifies key areas of healthcare concerns to “support healthcare organizations in their efforts to proactively identify and respond to threats to patient safety.” 

Their most recent report identifies the ten items below as the top areas of concern::

1. The pediatric mental health crisis

2. Physical and verbal violence against health care 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 or 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

The following are summaries for a few concerns from the report that overlap with risk areas that COPIC focuses on: 

Physical and Verbal Violence Against Healthcare Staff

Workplace violence can stem from disruptive providers, bullying among staff, or from patients and their families. Data reporting on workplace violence in healthcare is limited and inconsistent, and there is a concerning acceptance among many health professionals that a certain level of violence directed towards them is expected. Recommended actions from the report include:

• Formalize a workplace violence program utilizing an oversight committee.

• Encourage reporting of physical and/or verbal abuse from patients.

• Establish and support compliant processes that permit clinicians to terminate patient relationships. Utilize a behavioral emergency response team of trained individuals; ensure that employees know when and how to activate this team.

• Offer training for prevention, early recognition, management, and de-escalation of violent situations through simulation drills.

Delayed Identification and Treatment of Sepsis

Annually, approximately 1.7 million adult Americans develop sepsis, and it remains the leading cause of death in U.S. hospitals. Additionally, up to half of sepsis survivors experience post sepsis syndrome, leading to long-term cognitive difficulties, post traumatic stress disorder, and reduced quality of

life. Timely identification and treatment are crucial: intravenous antimicrobials should be administered immediately, ideally within an hour of recognizing septic shock, and within three hours for patients with possible sepsis without shock. Recommended actions from the report include:

• Develop organizational sepsis treatment safety goals with dedicated executive sponsorship and accompanying action plans and metrics.

• Establish sepsis treatment protocols or bundles integrated into the electronic health record (EHR) with an early warning scoring system.

• Educate patients and family members about infection prevention, sepsis warning signs, and appropriate actions to take.

• Integrate sepsis diagnostic tools into the clinical workflow, ensuring ease of use and minimal technical expertise requirements.

Medication Errors Resulting from Inaccurate Patient Medication Lists

It is reported that up to 50% of medication errors and 20% of adverse drug events can be attributed to this issue. Errors in medication reconciliation are prevalent during hospital admission, with 36% of patients experiencing such errors, primarily during the medication history gathering phase. Studies have shown that medication histories often contain errors, such as including medications that patients were no longer taking or omitting necessary medications. Discrepancies in medication reconciliation can also occur at discharge, potentially causing problems in general practice. Recommended actions from the report include:

• Standardize the medication reconciliation processes.

• Address organizational factors that contribute to rushed or inaccurate medication histories.

• Engage patients in medication management.

• Create distraction-free environments for collecting and documenting medication information.

• Implement continuous improvement activities through training and coaching.

Sue Sgambati, MD, is a part of the COPIC Department of Patient Safety and Risk Management

Link to the full report: www.ecri.org/top-10-patient-safety-concerns-2023-special-report