Diagnostic Errors Tops New List of Patient Safety Concerns

Marcia Frellick

March 13, 2018

The ECRI Institute has ranked diagnostic errors the number 1 fear in this year's Top 10 Patient Safety Concerns for Healthcare Organizations .

The institute notes that each year about one in 20 adults experiences a diagnostic error. Gail M. Horvath, MSN, RN, CNOR, CRCST, patient safety analyst for the ECRI Institute, writes in a press release that even some hospital errors said to be caused by the natural progression of disease "may have been the result of diagnostic error."

The institute suggests using algorithms to help avoid biases that can cause errors and better capturing of data on errors and near-misses to help systems learn from the errors in a nonpunitive way.

"Clinical decision support interventions can also be helpful by identifying ordered tests that haven't been done or by flagging incidental findings that require follow-up," Horvath adds.

The number 2 concern is opioid safety.

Stephanie Uses, PharmD, MJ, JD, patient safety analyst and consultant for the ECRI Institute, writes in the release, "We recommend that clinicians carefully assess patients for opioid use disorder and set realistic expectations about pain."

Remaining Safety Concerns

The next eight top concerns are:

3. Care coordination within a setting

4. Workarounds

5. Incorporation of health information technology into patient safety programs

6. Management of behavioral health needs in acute-care settings

7. All-hazards emergency preparedness

8. Device cleaning, disinfection, and sterilization

9. Patient engagement and health literacy

10. Leadership engagement in patient safety

SIDM Responds

The Society to Improve Diagnosis in Medicine (SIDM) commented in a press release Tuesday that it applauds the ECRI Institute for highlighting diagnostic error prominently "and noting that it is a both cognitive and systemic problem."

"We join them in calling on healthcare organizations to measure, report and develop initiatives to improve the diagnostic process," Paul Epner, SIDM's CEO, writes.

SIDM has convened the Coalition to Improve Diagnosis to engage patients, clinicians, and health systems in reducing diagnostic errors.

How the List Is Compiled

The concerns on the list aren't necessarily the most frequent or severe, William Marella, MBA, MMI, from the ECRI Institute's Patient Safety Organization (PSO), says in the press release.

"Rather, this list identifies concerns that have appeared in our members' inquiries, their root cause analyses, and in the adverse events they submit to our (PSO)," he says.

According to the release, since 2009, the PSO has received more than 2 million event reports and evaluated hundreds of root-cause analyses.

The Agency for Healthcare Research and Quality has designated the ECRI Institute as an Evidence-based Practice Center. The ECRI Institute offers open access to the report's executive brief at www.ecri.org/PatientSafetyTop10.

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