10 top patient safety issues for 2016

Written by Shannon Barnet, Max Green and Heather Punke | January 12, 2016

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Healthcare has no doubt made giant strides in patient safety in recent years: According to an HHS report released in
December, hospital-acquired condition rates dropped 17 percent from 2010 to 2014, leading to 87,000 fewer patient
deaths in hospitals. However, there is always room for improvement in the journey toward zero patient harm.
Several issues arose in 2015 that shed new light on patient safety threats.
The Becker's Infection Control & Clinical Quality editorial team chose the following 10 patient safety issues for
providers to consider in 2016, presented below in no particular order, based on the events and trends from 2015.
Medication errors. The Agency for Healthcare Research and Quality calls medication errors "one of the most
common types of inpatient errors," as nearly 5 percent of hospitalized patients are affected by adverse drug events
annually. New evidence uncovered in 2015 shows that medication errors are not just a problem for inpatients: They
abound during surgeries as well.
In fact, medication errors occur in some form in nearly half of all surgeries, according to research from Massachusetts
General Hospital published in October. Mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated
by a patient's vital signs, and documentation errors were the medication errors that occurred most frequently.
"We definitely have room for improvement in preventing perioperative medication errors, and now that we understand
the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent
them," said Karen Nanji, MD, lead author of the study.
Diagnostic errors. Diagnostic errors were thrust into the spotlight late in 2015 thanks to an Institute of Medicine
report titled "Improving Diagnosis in Health Care." The report asserts that diagnostic errors account for 6 to 17
percent of hospital adverse events and roughly 10 percent of patient deaths, indicating definite room for improvement
in this space.
"The report launched an important conversation about a serious patient safety issue with broad impact across the
continuum of care," Tejal Gandhi, MD, president and CEO of the National Patient Safety Foundation, wrote in a
December blog.
The new year provides an opportunity for hospitals to focus efforts to improve this serious patient safety issue. The
IOM report outlines several possible solutions to remedying diagnostic errors, including partnering with patients and
their families, as well as fostering teamwork between and among healthcare providers.
Discharge practices to post-acute, home care. Hospital discharge can be a critical moment in a patient's care. A
study from the early 2000s found nearly 20 percent of patients experience an adverse event within three weeks of
discharge, and many of those events could be prevented.
This important safety issue necessitates more attention in 2016 thanks to the launch of the Comprehensive Care for
Joint Replacement model in April. The CCJR will make hospitals responsible for the care quality and cost of joint
replacement patients for a full 90 days post-discharge, giving hospitals a financial incentive to focus on this important
patient safety issue.

Workplace safety. It is hospitals' duties to keep patients safe, but some experts argue patients cannot be safe unless
healthcare workers feel safe themselves.
"If healthcare providers are safe, then we will have safer patients," says Deborah Grubbe, a healthcare consultant
with DuPont Sustainable Solutions. "Because healthcare providers won't have to focus on their own safety and
thinking they'll get hurt, [they'll] be able to spend all their energy and alertness in providing good care for the patient."
This sentiment applies to a myriad of worker safety issues, from needlestick injuries to injuries from lifting patients to
fear of being assaulted by a patient.
Unfortunately, these staff safety issues are still a problem moving into 2016. To that end, the U.S. Department of
Labor's Occupational Safety & Health Administration launched a webpage in December 2015 providing information
and strategies for healthcare workplace violence awareness and prevention.

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Hospital facility safety. Issues with hospitals' facilities can sometimes put patient safety at risk. Several times in
2015, the safety of hospital patients was compromised or nearly compromised because of building or maintenance
problems. For instance, a Florida Agency for Healthcare Administration report released in April cited one Florida
hospital's handling of a sewage leak as a patient safety issue, including its failure to ensure the sewage was cleaned
up properly and failure to conduct an infection control risk assessment. The investigators also reported finding live
rats above the affected ceiling tiles and air conditioning supply vents leaking condensation over food prep tables.
Legionnaires' disease is another issue tied to the structure of a hospital, as Legionella outbreaks "are commonly
associated with buildings or structures that have complex water systems, likehospitals," according to the CDC.
In 2015, several organizations from the healthcare, construction and engineering industries formed a task force to
create uniform guidelines for the heating, ventilation and air condition of operating rooms, sterile processing
departments and endoscope procedure rooms to ensure patient safety.
In light of these issues and events, hospitals may wish to consider re-evaluating the maintenance protocols for their
facilities to ensure patient safety this year.
Reprocessing issues. The issues surrounding certain medical scopes and their link to infections resurged in 2015
and are sure to carry over in to 2016 as healthcare providers hone best practices to prevent further scope-related
incidents. In fact, the ECRI Institute listed "inadequate cleaning of flexible endoscopes before disinfection" and the
resulting risk of infection at the top of its 2016 Top 10 Health Technology Hazards list.
Experts have emphasized the importance of using the right tools and following protocol to the letter to prevent
infection, while some hospitals have begun culturing scopes after reprocessing to check for bacteria. Meanwhile,
some members of an FDA advisory panel recommended mandatory sterilization of duodenoscopes to prevent spread
of infection.
Sepsis. According to the CDC, more than 1 million cases of sepsis occur each year, and up to half of people who get
sepsis will die, making it the ninth leading cause of disease-related deaths. While sepsis is not a new patient safety
concern, it gets a new spotlight for 2016 thanks to CMS: The agency added the Severe Sepsis and Septic Shock
Early Management Bundle to the fiscal year 2016 Inpatient Prospective Payment System Final Rule.

"What's driven much of CMS' response to sepsis is the gradual increase in sepsis across the nation," Edward O.
Blews III, MD, assistant professor of infectious disease and associate medical director of hospital epidemiology at
Loma Linda (Calif.) University Medical Center, said in a December webinar on sepsis protocols.
Hospitals that meet compliance with the sepsis early management bundle can help lower sepsis mortality as well as
costs associated with treating sepsis (which, according to Mike Abrams, president and CEO of the Ohio Hospital
Association, can reach anywhere from $22,000 to $57,000 per case).
"Super" superbugs. Superbugs defined by Brian K. Coombes, PhD, of McMaster University in Ontario as
bacteria that cannot be treated using two or more antibiotics continue to pose a threat to patients, and they appear
to be getting stronger: A CDC report published in December revealed a particularly dangerous set of CRE strains is
cause for public health concern in the U.S. "Newly described resistance in Enterobacteriaceaehighlight[s] the
continued urgency to delay the spread of CRE," the report reads.
The strains have been named the "phantom menace" by some scientists, and they aren't the only superbugs
infectious disease specialists and healthcare providers will be keeping an eye on in 2016 researchers in China
published data on a bacteria found in pigs, broiler chickens and humans that contains a gene that makes it resistant
to all forms of antibiotics, including "last resort" drugs used to beat the toughest antimicrobial resistant bugs. The
gene responsible for resistance is called mcr-1, and has also been identified in Denmark. The gene has been found in
E. coli and Klebsiella pneumoniae bacteria, according to the Chinese study.
Small steps like boosting the focus on antibiotic stewardship can be taken this year to help combat the spread of
these surreal-sounding organisms.
The cyber-insecurity of medical devices. In July 2015, the U.S. Food and Drug Administration issued an official
warning to hospitals asking they reconsider using the Hospira Symbiq Infusion System, a computerized pump that is
widely used to deliver general infusion therapy, after it became apparent that with some ease, hackers could remotely
access the device and alter dosages.
But experts have been sounding the alarm on the cybersecurity of medical devices for some time now. In 2011, Jay
Radcliffe, senior security consultant and researcher for security data and analytics company Rapid7, wowed
audiences at the Def Con hacking conference in Las Vegas when he hacked his own Medtronic insulin pump.
Cybersecurity concerns have graduated from a health IT-specific worry to one that carries patient safety risks serious
enough to be on everyone's radar. Many medical devices connect to and operate on hospital networks that are
already rife with vulnerabilities, and even if the goal isn't to hurt patients who may be connected to the devices,
hackers can hopscotch onto the network from the device's entry point, gathering protected health information and
exploiting vulnerable data.
In the next year, there will likely be some organized pushes to secure those devices or at least a push to put
manufacturer, federal and healthcare providers' feet to the fire to start drumming up solutions.
Going transparent with quality data. Most health systems query patients about their experiences and satisfaction
with physicians during their hospital stays. But few opt to put those ratings online for all to see, although there's
reason to believe the practice can improve patient safety.
"When everyone physicians, patients, institutions, and the press is privy to data on performance, physicians will
develop a greater sense of accountability to deliver quality care," Ashish K. Jha, MD, a patient safety researcher at

Harvard University's School of Public Health in Cambridge, Mass., wrote in a post on Harvard Business Review in
October.
Aggregated ratings can be helpful learning tools for reviewing individual employee performance, and they also
incentivize medical staff to double check their work and pay more attention to areas where slip-ups can impact their
ratings, and ultimately the safety of those in their care. At some institutions, ratings are displayed internally, enabling
side-by-side comparisons that might produce insights into best practices or encourage a healthy sense of
competition.
In the future, this kind of openness could become a necessity for hospitals and health systems who want to compete
in a market with an increasing focus on transparency.
In addition to fostering quality improvement, facilitating this kind of feedback and discussion has the capacity to
highlight low points in patient care of which administration may not have previously been aware.
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