By: Karen P. Zimmer, MD, MPH, FAAP
Ever since Dick Clark featured the American Bandstand Top Ten to
unveil the 10 most popular songs for the week, such lists have become
ubiquitous. We use them to get ideas in selecting music, movies, books, places
to visit, things to do, trends to watch, and more.
We could probably identify the top 10 reasons why top 10 lists
are so popular, but suffice it to say that the lists give us a way to focus on
a particular issue or choice. When we scan a top 10 list, we compare it to our
own experiences. Have I heard that song? Seen that movie? Read that book?
Visited that place?
This year, ECRI Institute is publishing its Top 10 Patient
Safety Concerns for Healthcare Organizations with the same intent: to give
healthcare organizations a gauge to check their track record in patient safety.
The list originally appeared in our Healthcare Risk Control (HRC)
System newsletter, the Risk Management Reporter, and is reprinted
in this report. The list is partly based on more than 300,000 patient safety
events, custom research requests, and root-cause analyses submitted to our
federally designated patient safety organization, ECRI Institute PSO, for
evaluation and analysis.
Healthcare organizations can use the list to guide their own
discussions about patient safety. Look at the list to ask whether any, some, or
all of the top 10 areas identified are a concern for your organization. Your
organization may decide to use the findings to identify one or more performance
No two organizations will have the same response to our top 10
list, and every organization will likely identify their own areas of concern
outside of our top 10 list. The list is not meant to dictate areas to address
but rather enhance and inform those internal discussions about patient safety.
We intend to publish our top 10 list of patient safety concerns
on an annual basis. Use it along with ECRI Institute’s other two top 10
lists—our list of health technology hazards and our list of technologies to
watch—to stay informed in all areas of patient safety.
ECRI Institute is providing free access to a number of
educational tools at www.ecri.org/PatientSafetyTop10, including: full
report, a PowerPoint slideshow that summarizes the Top 10, and a poster.
By: Leah M. Addis
Do you remember when AOL was the thing? You didn’t have “the Internet,”
you had “AOL.” Every time you logged on, you’d see this screen:
And then, as chat rooms and AOL Instant Messenger rose in popularity
and paved the way for text messaging on cell phones and later smart phones,
something else started to take off: TXT speak (which is apparently known
officially as SMS language
TXT speak gave rise to some great jokes, like this one:
I always thought those jokes were hilarious! And then, I was clicking through
one night, and all of a sudden,
there it was, staring at me. An acronym I didn’t recognize.
What did it mean? I opened the article. It wasn’t spelled out. I was
distraught for two reasons, First, what could TL;DR possibly mean? And second,
how was I unable to figure it out?*
The problem with language is that it can very quickly become
specialized—either by location
. And when people from within one bubble communicate with someone
from another bubble, each of them are applying their own experiences,
perspectives, knowledge, and mindset to everything they say. They can each say
exactly the same thing, but mean something entirely different.
For example, take the phrase, “I know.” Think of how a 13-year-old says
it after being told to clean his room again. Now, think of how a 67-year-old
patient says it after hearing confirmation about her progressive condition’s
Hear the difference? That’s precisely why communication is tricky.
Language becomes imbued with meaning—not just from the definitions of the words
used, but from inflection, cultural significance, and a whole host of other
factors that come together in unique combinations for each person. (My inner
philosophy major is screaming to tell you how language
then turns around and shapes cultural consciousness
, but that’s a
discussion for another day.)
It’s worth taking the extra few moments to ensure that you’ve been as
clear as possible in situations when it’s crucial that you are understood. Techniques
such as teach-back
can be invaluable, but only once a rapport with a patient and family have been
established. If the patient is comfortable enough to ask questions, the way to
a productive dialogue is open. The onus in such circumstances tends to be on
the healthcare provider to ensure the clarity
message, and to empower the patient to ask
When it’s important that the message is received, it must be delivered
in a way that is easily receivable.
And, as our language continues to evolve, as slang continues to develop, and yes, as shorthand gets even shorter, that becomes a challenge for everyone.
Oh, and by the way, TL;DR means “Too Long; Didn’t Read.”
* Now, I’m about three months
younger than the first Mac. My dad worked at Drexel University when they first required every student to have a
Macintosh. I grew up with a
computer—with that computer. I’m no programmer, but I’m pretty darn competent,
if I say so myself. Ol’ Mac laughed at me as I ran full speed into my mid-life
By: Leah M. Addis
When it comes to electronic health records, computerized
provider order-entry, and other data input systems, we talk about copy-paste. A
lot. We typically agree that while it has its place in other applications, it’s
just too risky in healthcare.
Believe me, I know about copy-paste. I’m a writer. I know
the bad (I reviewed student papers for the tutoring center when I was in
college; it always stunned the freshmen that I could identify, in about two
seconds flat, the paragraphs that they’d pasted from some online resource) and
the good (copy-paste is a wonderfully efficient way to rearrange paragraphs in
So, now that my credentials are established, let me share an
anecdote. We use templates for practically all of our publications. When we
finalize a draft, it goes off to be edited and to be set in a predetermined
layout. Then there’s copyediting and a whole system to make sure that each step
happens, so that our final product is as clean and polished as possible.
Well, recently, our system did not work. It failed. And we
sent out an e-mail item that had only been partially laid out in the
prepopulated template. It looked complete at first glance; because there was no
glaring blank space, there was nothing to quickly signal to us that the layout
was actually incomplete.
We unnecessarily opened ourselves up to risk because we’d
been using copy-paste.
Of course, since it’s relatively easy to fix and resend an e-mailed
newsletter, the error did not have lasting harm. But, the ease with which this
error happened was very sobering. (And yes, we corrected our templates and
system going forward so the error is not repeated.)
The takeaway is this: use copy-paste during data input at
your peril. When you’re rushing, when you’re not paying close attention, when
you’re distracted, you are opening the door to the risk of missing a data field
that is not correct, up-to-date, or finalized. At a glance, your work may look
complete, with no obvious cue, such as a blank field, that something is missing,
outdated, or incorrect.
And when that can negatively affect a patient, there’s a
small fix with a big outcome: better to not use copy-paste at all.
By: Leah M. Addis
In reviewing our brilliant copyeditor’s comments on an
article I had just finished, I came across one about using an RFID (radio
frequency identification) wand to locate tagged items inadvertently retained in
a patient. “Sounds like magic!” he wrote. Being a non-clinical staffer here at
ECRI Institute myself, I agreed wholeheartedly, and typed back, “Accio
with a flick of my wrist and flourish on the keyboard for good measure.
Then I paused. Really, so much of what healthcare providers
do is practically magic to patients.
My first project for Healthcare
Risk Control, some years ago now, was on pulse oximetry. Really simple
thing, right? The clip goes on the patient’s finger, the sensor does its thing
and voilà, the patient’s Sp02 shows up on the screen.
But, take a minute to think about it—I mean really think
about the technology that goes into this tiny sensor. It measures wavelengths
of light that pass through your fingertip—specifically, through the blood
that’s coursing through you. Lightwaves passing through pulses of blood are
used to measure the amount of oxygen in that blood.
Come on, that’s magic!
Arthur C. Clarke puts it best: Magic is just science that we
don’t understand yet. One hundred years ago, things we don’t have a second
thought about doing now weren’t even pipe dreams. For example, MRI scans
were proven theoretically feasible between the 1950s and the 1970s, but the MRI
design wasn’t fine-tuned until the 1980s.
for that matter, isn’t even old enough to have a mid-life crisis yet.
Healthcare providers use such advanced technology so
frequently that it could be easy to be desensitized to the sheer impressiveness
of the technology. It’s easy to forget that the most advanced technology many
patients work with on a daily basis is a laptop or smart phone. So when the
sixty-third patient today asks “Ooh, what does that do?” remember that we
muggles think you’re doing magic.
Because to us, you are.
Institute PSO turned five. Along the way, we hit some major benchmarks—we’ve
expanded our staff with a variety of specialties; we’ve created, updated, and
recreated our data collection and analysis systems; and we’ve received and
analyzed more than 350,000 events.
Institute PSO we provide a means to exchange and share issues and concerns, as
well as successes, to enhance the delivery of healthcare,” says Karen P.
Zimmer, MD, MPH, FAAP, Medical Director of ECRI Institute PSO and Patient
Safety, Risk and Quality Group.
Institute, the parent organization of ECRI Institute PSO, strives to keep
improving—it is part of our mission to constantly strive to improve patient
safety through research.
“We focus on
process improvement,” says Zimmer. “Both in how we address event issues, such
as our approach to investigation, and in the events themselves. We recognize
that the issues are multifactorial and the human element is one piece of the
A focus on
that human element is also a strength of ECRI Institute. Explains Kelly C.
Graham, BS, RN, “It should not be forgotten, no matter how many events we see,
there are still people—both patients and staff—affected by each and every one.”
adds Zimmer, “there’s always more work to be done. Healthcare is such a
complex, integrated delivery system that we often need to implement strategies
at different points in the process.”
there’s a willingness to fix the problem, or to recognize that there is one,”
Zimmer says. “There’s been an incredible culture shift overall. When I was a
resident, patient care was seen as ‘one doctor, one patient.’ The shift to a
team approach has benefited patients, and the PSO has encouraged it. There’s
discussion, sharing, and understanding that issues are systemic rather than the
fault of individuals.”
Anniversary, ECRI Institute PSO. Here’s to many more.
us, and let us demonstrate how we can help you. This resource appeared in
our PSO Monthly Brief – sign up for free