Use These Patient Safety Tools to Address the 2023 ECRI Report

LHA Trust Funds provides patient safety tools to address five key patient safety issues highlighted in ECRI’s annual Patient Safety Concerns report.

Ways to improve patient safety top the Louisiana healthcare provider wish list every day.

We are providing your healthcare organization with the relevant resources you need to improve patient safety quickly. This month, LHA Trust Funds showcases our toolkits addressing five key issues highlighted in ECRI’s Top 10 Patient Safety Concerns 2023 special report.

Use our collection of patient safety tools to create or evaluate your education or processes regarding these urgent healthcare issues.

1. Physical and verbal violence against healthcare staff

We know that workplace violence against healthcare workers is a serious issue for Louisiana healthcare providers as well as a nationwide epidemic. Healthcare workers are five times more likely to experience workplace violence than employees in all other industries, according to the Bureau of Labor Statistics.

That’s why we focus on providing resources to prevent workplace violence for all types of healthcare facilities and providers in our state.

“Workplace violence in healthcare has become so common, that some may feel that certain amounts of violence directed towards them is an expected part of the job. But it shouldn't be that way,” says Shannon Davila, who currently serves as the Director of ECRI’s Total Systems Approach to Safety, in a recent webinar.

In addition to the strategies provided by the ECRI report, visit our specialized toolkits focusing on various aspects of the issue.

  • Our Active Shooter Response and Preparedness Toolkit helps healthcare facilities and practices create or refine emergency response plans in the event of an active shooter incident.
  • Our Security in Healthcare Toolkit guides healthcare organizations in planning an effective security program with best practices, risk assessments, sample policies, and other resources.
  • Our Violence Prevention Toolkit supports healthcare organizations seeking to develop or assess an existing comprehensive violence prevention program for staff members.

“Our toolkits are compiled with the needs of our members in mind,” says Stacie Jenkins, Vice President of Patient Safety and Risk at LHA Trust Funds. “They contain tools and information that represent best practices in healthcare violence prevention and management.”

2. Delayed identification and treatment of sepsis

Sepsis is the leading cause of death in U.S. hospitals each year, and Louisiana continues to lead the country in sepsis mortality rates, according to the Centers for Disease Control and Prevention.

Part of the problem is that patients who show symptoms of being septic are being diagnosed and treated for the condition later than they should be. Our Sepsis Prevention Toolkit gives recommendations about organizing a sepsis identification program to improve both the safety and outcomes of vulnerable patients within your facility.

The toolkit also offers quality improvement materials designed to help address staff performance and raise their awareness about best practices for treating sepsis and septic shock, including clinical practice guidelines from the Surviving Sepsis Campaign.

“Early diagnosis and treatment of sepsis is the key to reducing the significant mortality it is associated with,” Jenkins says. “Our toolkit offers sample assessment tools, pocket guides, and staff educational information to help improve early identification of sepsis.”

3. Risks of not looking beyond the “five rights” to achieve medication safety

The five “rights” — right patient, drug, dose, route, and time — are considered the standard for medication safety. However, medication errors cannot solely be explained by a violation of one or more of these “rights.”

“Strict adherence to the five rights falsely implies that medication errors will be prevented,” Davila says. “However, the five rights should be reviewed as foundational goals or as a medication safety framework, not as strategies to achieve medication safety.”

When the five rights are considered a medication safety framework, nurses and other healthcare workers should then be held accountable for following your organization’s medication safety procedures.

Our Medication Safety Toolkit provides safety and quality guidelines about medication administration processes and how to identify potential risks that may cause errors from the American Academy of Pediatrics, American Society of Health-System Pharmacists, and the Joint Commission among others.

“Many advances have been made over the years to add hard stops into the medication safety process to prevent human error,” Jenkins says.

“But it is important to make sure the processes are in place and effective through various methods of risk identification strategies. Our toolkit provides information on best practices to prevent adverse medication errors and tools for monitoring the effectiveness of your program.”

4. Medication errors resulting from inaccurate patient medication lists

Inconsistent knowledge and record-keeping about medications cause up to 50% of medication errors in hospitals and up to 20% of adverse drug events, according to the Institute for Healthcare Improvement.

As a result, an effective medication reconciliation process is vital for patient safety.

“Leaders can identify and address organizational factors that contribute to rushed or inaccurate medication histories such as shortened appointment times, and incomplete medication lists,” Davila says.

“Engage patients on prescribing new medication and, prior to the medication administration, reinforce the importance of maintaining that current med list and bringing it with them to every encounter.”

The Medication Safety Education section of our Medication Safety Toolkit provides a robust range of medication education tools for staff members, patients, and families. These resources include information about safe medication practices, ways to help patients keep track of their current medications, and the medication reconciliation process within your practice or facility’s care settings.

5. Accidental administration of neuromuscular blocking agents

Neuromuscular blocking agents (NMBs) paralyze skeletal muscles during mechanical ventilation and can cause catastrophic injuries or death when used in error. The Institute for Safe Medical Practices has received more than one hundred reports about accidental NMB administration since 1996. Most of those errors resulted from administering or compounding an NMB instead of delivering the intended drug to a patient.

“Leaders really need to model behavior like Champions for Change and the redesign of some of these systems around how these meds are stored and accessed,” Davila says.

The Safe Medication Practices section of our Medication Safety Toolkit gathers some of the best tools and resources from the ASHP, ISMP, and other national organizations to implement safe practice guidelines regarding high-alert medications in healthcare facilities.

“A lot of work has been done to improve the safety of all medication delivery, but still more needs to be done,” Jenkins says.

“In addition to hard stops, efforts should be made to ensure that other human factors are considered and mitigated such as distraction, fatigue, workload, and floating staff to areas where they are unfamiliar. Our toolkit has the information and tools to help support this improvement process.”

Improving Patient Safety

ECRI’s Top 10 Patient Safety Concerns 2023 report highlights issues at the forefront of healthcare provider minds nationwide. Our goal is the same — helping Louisiana healthcare organizations improve patient care and outcomes.

Interested in more patient safety tools? Visit our complete toolkit library sorted by topic.

For more information on the 2023 ECRI Top 10 Patient Concerns Report, watch our webinar with Shannon Davila on-demand.