The Becker's Clinical Leadership & Infection Control editorial team chose the following 10 patient safety issues for providers to prioritize in 2018, presented below in no particular order, based on news, study findings and trends reported in the past year.
1. Disparate EHRs. While EHR adoption continues to increase among healthcare providers, interoperability remains a challenge. A KLAS Research report released in October shows only 14 percent of 420 survey respondents at hospitals and clinics indicated they have "deep interoperability" when sharing data among different EHRs. This figure is up 6 percent from a year prior.
Disparate EHRs can negatively affect patient care. A lack of interoperability may mean providers are not getting the whole picture when it comes to their patients' conditions. Information management in EHRs topped ECRI Institute's annual list of top patient safety concerns for healthcare organizations. One of the most concerning ways poor interoperability affects patient care is medication reconciliation. If physicians are unaware of all the medications a patient is taking, they may unknowingly prescribe a drug that can negatively interact with another medication. The College of Healthcare Information Management Executives Foundation polled 120 hospital CIOs, CMIOs, directors of informatics and other hospital administrators in February 2017, and found 74.8 percent listed incomplete and inaccurate medication data as a top concern.
Lack of EHR interoperability also makes effective patient care harder in times of crisis or during natural disasters. Consider when Hurricane Harvey hit Texas hospitals in August; data exchange between unaffiliated facilities was difficult in the storm's aftermath, Wired reported. Poor interoperability complicated the care process for displaced patients who sought treatment at hospitals that did not have access to their medical records.
2. Hand hygiene. A lack of proper hand hygiene compliance was directly linked to numerous infections and death in 2017. In July, state health officials identified poor infection control practices at West Columbia, S.C.-based Vitality Medical Center, where six knee pain patients were sickened with Staphylococcus aureus infections in December 2016. The health officials noted improper protocols, such as not conducting proper hand hygiene practices or wear sterile gloves when performing knee injections, led to the spread of infection at the clinic.
However, a number of studies published in 2017 found evidence some interventions can help improve hand hygiene compliance. Supplying patients with handheld signs to remind physicians to wash their hands can help improve provider hand hygiene compliance, according to a study published in the American Journal of Infection Control. Non-conventional methods have also been successful at improving hand hygiene compliance rates. A study published in the American Journal of Infection Control showed text messaging via smartphones can significantly increase hand hygiene adherence among healthcare workers.
3. Nurse-patient ratios. Inadequate staffing at healthcare facilities can greatly hamper patient care. A study published in the International Journal of Nursing Studies showed every extra patient on a nurse's caseload increased mortality rates by 7 percent. Another study published in the Annals of Intensive Care found intensive care unit patients exposed to a high workload-to-nurse ratio for one or more days had lower risk-adjusted odds of survival to hospital discharge compared to patients exposed to normal ratios.
In May, Rep. Jan Schakowsky, D-Ill., and Sen. Sherrod Brown, D-Ohio, reintroduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act in the House. The bill "sets minimum nurse-to-patient staffing requirements for direct-care registered nurses, requires a study of staffing requirements for direct care licensed practice nurses, and provides whistleblower protections."
Individual states have also taken up the mantle of requiring minimum staffing ratios in healthcare facilities. As of September 2015, 14 states had enacted legislation or adopted regulations around nurse staffing ratios, according to the Agency for Healthcare Research and Quality. In 2017, Michigan legislators introduced a bill that would require hospitals to keep open records of nurse-patient ratios, develop staffing plans and ban mandatory nurse overtime.
4. Drug and medical supply shortages. Supply chain issues represented a major obstacle for healthcare providers in 2017, with shortages of drugs and medical supplies expected to continue in 2018. In May, many hospitals were forced to delay major operations and chemotherapy treatments due to a nationwide shortage of sodium bicarbonate solution. Mobile, Ala.-based Providence Hospital had to postpone seven scheduled open heart surgeries after a patient needed 35 of the hospital's remaining 175 sodium bicarbonate vials. While Pfizer — the drug's primary supplier — sent Providence Hospital an emergency supply, the hospital still faced a shortage in the following weeks and months.
Hospitals across the U.S. are also battling drug and medical supply shortages caused, in part, by lower production levels at manufacturing plants in Puerto Rico, which lost power after Hurricane Maria made landfall in late September 2017. Puerto Rico, which houses more than 80 drug and medical device plants, produces nearly 10 percent of the U.S.'s medications. The most notable shortage to hit hospitals was small saline bags, which were already in low supply before the hurricane made landfall.
In October, FDA commissioner Scott Gottlieb, MD, said hospitals nationwide could see a shortage of about 40 drugs and medical devices due to manufacturing disruptions on the island. "Some of these products are critical to Americans," Dr. Gottlieb told the House Energy and Commerce Committee's Subcommittee on Health. "A loss of access could have significant public health consequences."
5. Quality reporting. CMS Administrator Seema Verma acknowledged issues with the agency's current quality reporting system during a speech at the Health Care Payment Learning and Action Network Fall Summit in October 2017. "There are many steps involved in submitting them, taking time away from patients," she said. "Moreover, it's not clear whether all of these measures are actually improving patient care."
The agency rolled out the "Meaningful Measures" initiative Oct. 30, which aims to reduce the regulatory hurdles associated with quality reporting. CMS plans to simplify the measures hospitals and physicians must report on, zeroing in on the most important measures to improve care quality and patient outcomes. The agency also launched "Patients Over Paperwork" in October, an initiative aimed at identifying unnecessary burdens and inefficiencies that prevent healthcare providers from spending time with patients.
6. Resurgent diseases. The U.S. saw several historic outbreaks of vaccine-preventable viruses in 2017 amid waning immunity and low vaccine adherence in certain pockets of the country. Minnesota experienced its largest measles outbreak since 1990. The outbreak lasted April 11 to July 13, resulting in 79 measles cases and 22 hospitalizations. Sixty-four of the cases occurred among the Somali Minnesotan community. Immunization rates among this population declined in recent years due to the spread of misinformation regarding vaccine safety.
Scarlet fever is also reemerging in certain parts of the world for reasons unknown to researchers and health officials, Vox reported in late November. England and Wales saw three times the amount of scarlet fever cases in 2014 compared to the year before, according to a study published Nov. 27 in Lancet Infectious Diseases. Vietnam, South Korea, Hong Kong and China have also reported significant increases in scarlet fever cases since 2009.
7. Mergers and acquisitions. Twenty-nine hospital and health system transactions were announced in the third quarter of 2017, putting annual transactions in 2017 on pace to surpass the 102 deals that occurred in 2016, according to an October 2017 Kaufman Hall report.
In some cases, hospital mergers, acquisitions and divestitures cause various changes in an organization's culture, leadership, equipment and operating environment that can pose a threat to patient care. In a 2015 op-ed published in JAMA, researchers from Baltimore-based Johns Hopkins Medicine argued hospital consolidation and reduced healthcare competition limits patient choice, hinders innovation that leads to better care and reduces hospitals' incentive to improve quality ratings. On the other hand, transactions that help to increase competition and diversify markets can also improve healthcare quality and services. Research from the Robert Wood Johnson Foundation also shows patients living in competitive healthcare markets exhibit better health outcomes and lower mortality rates than those who live in areas with less healthcare competition.
8. Physician burnout. Fifty-one percent of physicians experienced frequent or constant feelings of burnout in 2017, compared to just 40 percent in 2013, according to Medscape's annual survey. A major source of burnout stems from the large amount of data entry and clerical work physicians must complete on a daily basis. On average, physicians spend 50 percent of their work day entering data into EHRs and completing clerical work. Just 27 percent of their day is spent interacting with patients, according to a 2016 study published in Annals of Internal Medicine. Even when physicians do engage in patient encounters, 37 percent of the visit is spent on EHR documentation or desk work.
In March 2017, leaders from some of the country's most prominent health systems authored an article in Health Affairs on physician burnout. The healthcare executives argued addressing burnout should be a major priority for all healthcare leaders, as it can threaten patient safety, quality of care and increase healthcare costs.
9. Antibiotic resistance. The ongoing evolution of antibiotic resistance is poised to be a major patient safety concern for hospitals around the world in 2018. The issue has become so serious that the United Kingdom's Office for National Statistics lowered its estimates for future life expectancy to reflect "less optimistic views" of longevity with regards to increases in antimicrobial resistance, according to The Telegraph.
In February 2017, the World Health Organization ranked the world's 12 most-dangerous superbugs. Topping the list were three strains of bacteria resistant to the last resort antibiotic carbapenem. U.S. health officials will closely monitor several drug-resistant hospital-acquired infections in 2018, including, carbapenem-Enterobacteriaceae, which can sometimes be resistant to all available antibiotics. CRE infections carry extremely high mortality rates, with some studies suggesting 50 percent of infected individuals die, according to the CDC.
CRE cause an estimated 9,300 infections and 600 deaths every year in the U.S. A 2017 study published in PNAS found little evidence of person-to-person transmission of CRE, suggesting the bacteria could be spreading through U.S. hospitals in unknown and unmonitored ways. However, hospitals are not without resources in the fight against antibiotic resistance. Infection control leaders can look to organizations like the CDC, the National Quality Forum and the Society for Healthcare Epidemiology of America for tools to improve antibiotic stewardship and curb resistance.
10. Opioid epidemic. The nation's ongoing opioid addiction and overdose crisis presents numerous challenges for healthcare organizations, including drug diversion, rising rates of overdose deaths and secondary exposure to deadly synthetic opioids like fentanyl among frontline providers caring for overdose patients.
Curbing rates of adverse outcomes related to post-surgical opioids will likely be an important concern for healthcare leaders in 2018, as more evidence emerges highlighting the serious risk of addiction associated with opioid exposure. A June 2017 study published in JAMA Surgery cited prolonged opioid use as the most common complication among surgery patients who were not previously exposed to opioids.
In a Health Affairs blog post published in September of last year, three physician leaders argued hospitals should be penalized for opioid addiction if the condition develops as a result of hospital-based care that could have been prevented by adhering to evidence-based practices. Amid this environment, some leading health systems are taking serious efforts to reduce opioid use in their facilities. Salt Lake City-based Intermountain Healthcare pledged to cut opioid prescriptions by 40 percent by the end of 2018. The success of such initiatives will be something for healthcare leaders to watch closely this year.