Diagnostic Errors Top ECRI Institute’s Patient Safety Concerns for 2018

New report examines root causes for serious patient safety events

March 12, 2018

PLYMOUTH MEETING, PA—ECRI Institute names diagnostic errors the number one concern on its 2018 Top 10 Patient Safety Concerns for Healthcare Organizations. Each year, approximately 1 in 20 adults experiences a diagnostic error, according to published studies. These errors and delays can lead to care gaps, repeat testing, unnecessary procedures, and patient harm.

“Diagnostic errors are not only common, but they can have serious consequences," says Gail M. Horvath, MSN, RN, CNOR, CRCST, patient safety analyst, ECRI Institute. "A lot of hospital deaths that were attributed to the normal course of disease may have been the result of diagnostic error."

ECRI Institute suggests using structured tools and algorithms to help overcome cognitive biases that can lead to errors. When errors or near misses occur, organizations can capture data using a variety of methods and then develop non-punitive ways of learning from the errors.

“Clinical decision support interventions can also be helpful by identifying ordered tests that haven't been done or by flagging incidental findings that require follow-up," adds Horvath.

Opioid safety, second on this year's list, stretches across the healthcare continuum. “Opioids are a patient safety concern because of the seriousness of the side effects," says Stephanie Uses, PharmD, MJ, JD, patient safety analyst and consultant, ECRI Institute. "We recommend that clinicians carefully assess patients for opioid use disorder and set realistic expectations about pain."

ECRI Institute's 2018 list of patient safety concerns:
1. Diagnostic errors
2. Opioid safety across the continuum of care
3. Care coordination within a setting
4. Workarounds
5. Incorporating health IT into patient safety programs
6. Management of behavioral health needs in acute care settings
7. All-hazards emergency preparedness
8. Device cleaning, disinfection, and sterilization
9. Patient engagement and health literacy
10. Leadership engagement in patient safety

"The list does not necessarily represent the issues that occur most frequently or are most severe. Most organizations already know what their high frequency, high-severity challenges are," says William Marella, MBA, MMI, Executive Director, Operations and Analytics of Patient Safety, Risk and Quality, ECRI Institute PSO.

“Rather, this list identifies concerns that have appeared in our members' inquiries, their root cause analyses, and in the adverse events they submit to our Patient Safety Organization," adds Marella.

ECRI Institute PSO has received more than 2 million event reports and reviewed hundreds of root-cause analyses since 2009.

Healthcare organizations can use ECRI Institute's 2018 Top 10 Patient Safety Concerns for Healthcare Organizations to identify priorities and create corrective action plans. ECRI Institute is providing open access to the Executive Brief at The comprehensive report, available to ECRI Institute members, includes many additional resources.

ECRI Institute encourages organizations to adapt relevant patient safety interventions to meet each care setting. Although not all patient safety concerns on the list apply to all healthcare organizations, many are relevant to a range of settings across the continuum of care.

For information about working with ECRI Institute PSO, call (610) 825-6000, ext. 5558; e-mail; visit; or write to us at 5200 Butler Pike, Plymouth Meeting, PA 19462.

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About ECRI Institute
For 50 years, ECRI Institute's work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. The ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority.

For more information, contact:
Laurie Menyo, Director of Public Relations and Marketing Communications
(610) 825-6000, ext. 5310