ECRI Institute compiles a database of patient safety events. With more than 300,000 event reports, ECRI is in an ideal position to spot trends. Medical malpractice attorneys have likely seen many if not all of these issues surface during investigation of claims.
Here are the top 10:
- Data integrity failures with health information technology systems
- Poor care coordination with patient’s next level of care
- Test results reporting errors
- Drug shortages
- Failure to adequately manage behavioral health patients in acute care settings
- Mislabeled specimens
- Retained devices and unretrieved fragments
- Patient falls while toileting
- Inadequate monitoring for respiratory depression in patients taking opioids
- Inadequate processing of endoscopes and surgical instruments
Data integrity failures with health information technology systems
The huge push to implement electronic medical records has resulted in more than tripling of the use of these systems since 2009. At Med League, we increasingly see electronic medical records of varying quality and organization. ECRI points out that the integrity of data in health IT systems can be compromised by
- Data entry errors
- Missing or delayed data delivery
- Inappropriate use of default values
- Copying and pasting older information into a new report
- Use of both paper and electronic systems for patient care
- Patient/data association errors (patient data from a medical device is mistakenly associated with another patient’s record)
Here’s what we see at Med League as we attempt to analyze electronic medical record printouts:
- Reams of information that is repeated over and over every day of the admission
- Progress notes that are printed out in random order, making it difficult to follow the flow of events
- Almost total loss of narrative notes, making it hard to determine what transpired
- Progress notes that are copied and pasted from shift to shift, day to day, often repeating outdated information
- Mindless clicking of boxes (rote charting) resulting in inaccurate or inane chart entries
Our frustrations with electronic medical records affect interpretation of information after the fact. ECRI recognized the clinical risks to the patient while the care is being delivered. ECRI recommended
- Assessing the clinical workflow to understand how the data is or will be used by the frontline staff
- Testing the system and the associated interfaces, preferably in a simulated setting, to verify that the system is functioning as intended
- Providing sufficient user training and support
- Establishing a mechanism for users to report problems as they are discovered
