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ECRI Institute's Patient Safety Blog

ECRI Institute’s Newest Top 10

​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 improvement initiatives.
 
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.
TL;DR, or, Language vs. Communication

​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:

 
(Source: www.giphy.com)
 
 
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 BuzzFeed one night, and all of a sudden, there it was, staring at me. An acronym I didn’t recognize.
 
TL;DR
 
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, profession, culture, age, or gender. 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 bleak outlook.
 
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 and consistency of the message, and to empower the patient to ask questions about it.
 
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 crisis.
 
The Perils of Copy-Paste

​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 a draft).

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.
Medicine for Muggles

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 fragmentus!” 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.  Robotic surgery, 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.
Happy Anniversary, ECRI Institute PSO!

This past year, ECRI 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.


“At ECRI 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.

ECRI 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 puzzle."

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.”

“That said,” 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.”

“Nevertheless, 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.”

Happy Anniversary, ECRI Institute PSO. Here’s to many more.

Contact us, and let us demonstrate how we can help you. This resource appeared in our PSO Monthly Briefsign up for free here.

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