Top patient safety woes in 2023

Patient safety is top of mind for health systems and health plans, the majority of whom have adopted numerous health IT tools to help identify and mitigate risks before they become adverse events. 

Patients are actually safer than ever in the hospital, thanks in large part to digital tools like computerized provider order entry (CPOE). Yet gaps still remain in the technical infrastructure and human workflows designed to ensure that patients leave their encounters in better health than they arrived. 

Each year, ECRI and the Institute for Safe Medication Practices (ISMP) highlight the top ten risks that have the biggest impacts on patient safety. In the 2023 report, the most pressing concerns are largely split between communication errors leading to poor care coordination, clinician burnout and working conditions, and untapped opportunities to leverage technologies to ensure medication safety and prompt attention to gaps in care. 

“The items on this year’s list require that leaders make safety the top priority in the organization, that patients and families be partners in the design of safe care, and that healthcare workers be seen not as commodities, but as a valued resource that is mission critical,” the report states. 

Medication safety suffers from incomplete, inaccurate digital data 

Medication errors are tied to $40 billion in spending and up to 9000 deaths each year. ECRI and ISMP state that inconsistent record keeping and insufficient information about medications contribute to up to half of these errors in hospitals. 

More than a third of patients experience at least one medication reconciliation error at hospital admission, and more may experience mistakes upon discharge. With a whopping 91 percent of these errors considered clinically significant, there is an extremely strong imperative to make sure that medication lists are accurate, complete, and up to date both in the hospital and after an admission. 

Medication management technologies, including medication reconciliation tools, health information exchange, and CPOE, are crucial for aggregating medication lists, identifying errors, and preventing prescribing mistakes. 

But these tools must be implemented against a background of a strong culture of safety, ECRI says. The “five rights” of medication administration – right patient, drug, dose, route, and time – need to be part of a larger system of education, support, accountability, and open communication that encourages providers to report and discuss mistakes in a non-punitive environment. 

Organizations are encouraged to evaluate and iterate upon medication administration procedures, standardize medication reconciliation processes, employ technology to enhance provider workflows, and recognize “good catches” when staff identify errors before they reach the patient. 

Poor care coordination leads to preventable harm and delayed services 

Similarly, organizations need to invest time and resources in improving communication between and across care teams to bolster care coordination and promote timely delivery of care. 

This is especially important when dealing with sepsis, the report notes, which is extremely time sensitive. But care coordination is also vital for the management of chronic conditions, a $3.69 trillion concern that affects more than 6 in 10 US adults. 

“In a recent survey of 7,568 patients, nearly 40 percent (2,884) reported at least one gap in care coordination and nearly 10% reported at least one preventable outcome such as repeat tests, medication interactions, and ED visits or hospital admissions,” the report says. 

Many of these missed or repeated services are due to the lack of interoperability across disparate systems, leaving providers in the dark about what other members of the care team are doing. Health systems will need to continue investing in health information exchange capabilities and user-friendly EHR workflows that easily surface incoming data from partner providers. 

Leaders can further enhance care coordination by creating regular opportunities for care teams to meet and discuss shared processes, integrate family members and caregivers into patient care, and develop performance metrics to gauge the effectiveness of health IT and person-driven activities to reduce care gaps.   

Clinician burnout and uncertainty create challenges for organizational culture 

Technology only functions well when users have the time and cognitive bandwidth to correctly use it. Unfortunately, both clinicians and their patients are experiencing extreme stress that leads to unintentional mistakes and avoidable conflicts. 

ECRI and ISMP have flagged the pediatric mental health crisis as the biggest concern, pointing out the impact of the COVID-19 pandemic and the use of social media as major contributors to mental health distress among children and teens. Suicidal ideation is on the rise, with a 39 percent increase in the winter of 2021 compared with the same period in 2019. 

Not only is this a pressing problem for youth and their families, but it can affect the mental health and wellness of staff treating young people in crisis – especially when they are not properly equipped to provide mental health services in EDs and other non-behavioral health care settings.   

Combined with several other items on the list, including patient threats and violence toward care providers, uncertainty over national maternal medicine policies, and the ongoing staffing shortages forcing some clinicians to operate outside of their scope and core competencies, many clinicians are facing an overwhelmingly challenging working environment. 

The resulting burnout can make other patient safety errors more common, sparking a downward spiral of stress, mistakes, patient anger, and staff resignations.  

Organizations need to take a proactive role in changing the cultural dynamic through staff support and training, including professional development opportunities, staff surveys and assessments, process improvement, supportive technologies, and adequate staffing levels. 

By combining technologies to catch and prevent errors with organizational strategies to improve experiences and maximize resources, health systems can continue positive progress with patient safety and create an atmosphere where staff can also thrive.  

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.