Diagnostic Quality Heads ECRI’s Patient Safety List

In 2018 ECRI Institute released its list of the Top 10 Patient Safety Concerns for Healthcare Organizations and named diagnostic errors as the number one concern. In the report ECRI noted that diagnostic errors are “challenging to measure and learn from because they often go undetected until after the patient leaves the hospital or emergency department (ED). Healthcare organizations should capture data on diagnostic errors and near misses. Sources may include the event-reporting system, malpractice and payment claims, patient complaints, patient surveys, autopsies, and record reviews. The organization can then make changes to address gaps. Discussing the topic in multiple forums, such as grand rounds and debriefings, can support ongoing analysis and learning for clinicians.”

Each year, ECRI develops the Patient Safety Concerns list by reviewing events in the ECRI Institute Patient Safety Organization (PSO) database, PSO members’ root-cause analyses, medical malpractice data, research requests, and finally, votes from a panel of experts from inside and outside ECRI Institute.

When ECRI released their list for 2019 last month, it was notably different than the 2018 list. Rather than identifying the broad topic of diagnostic error, the new list included specific aspects of diagnostic quality that lead to patient harm and diagnostic errors. Bill Marella, executive director of ECRI’s PSO Operations and Analytics notes, “Diagnostic quality is an aspect of most everything on the list. Ensuring that accurate and timely diagnosis happens, and that it's communicated effectively, is so important. When that doesn’t happen it’s almost impossible for anything else to go right.”

Among the diagnostic quality concerns on the 2019 list:

#1 Diagnostic Stewardship and Test Result Management Using EHRs
“When diagnoses and test results are not properly communicated or followed up on, the potential exists to cause serious patient harm or death… To help ‘close the loop,’ providers must not only fully utilize an EHR designed to meet their practices’ unique needs, but also recognize the importance of clear communication, both among caregivers and between caregivers and patients.”

ECRI’s Partnership for Health IT Patient Safety developed a set of recommendations around safe health practices for closing the loop on test results.

#6 Detecting Changes in a Patient’s Condition
“Failure to detect changes in a patient’s condition is an ongoing patient safety concern across the continuum of care. Problems can arise within a care unit and during transitions of care within a facility and from one facility to another.”

#8 Early Recognition of Sepsis Across the Continuum
“Healthcare workers throughout the continuum of care must be able to recognize sepsis… To facilitate timely diagnosis and management, healthcare organizations across the continuum should have protocols for response when sepsis is suspected, much as they do for chest pain. Organizations may use checklists, tools, or algorithms to support the response.”

More than 5,000 healthcare institutions and systems worldwide—including four out of every five U.S. hospitals—are members of ECRI Institute and use their reports and product evaluations to guide their operational and strategic decisions. ECRI Institute joined the Coalition to Improve Diagnosis in 2018.

According to Marella, the ECRI Institute crafts its patient safety list with a C-suite audience in mind, “the list helps readers make the case internally with their C-suite that these are issues that are worth their attention.” ECRI hopes the document gets distributed to the board of directors at healthcare organizations and that the board uses it to drive their quality agenda.

Paul Anderson, ECRI’s director of risk management publications notes, “it's worth committing our time and energy to fighting the problem of diagnostic errors because we can improve patient safety, and if we're focusing on the top things on the ECRI lists maybe we can have a big impact.”

Executive Briefs for the 2018 and 2019 Top 10 Patient Safety Concerns for Healthcare Organizations are available on ECRI’s website.

In this Issue:
60+ Organizations Work to Improve Diagnosis

ECRI Institute, along with more than 60 leading healthcare organizations, make up SIDM Coalition to Improve Diagnosis -- a diverse collaboration focused on improving the diagnostic process.