Can You Name the Top 10 Patient Safety Risks in Your Hospital?

More than 36 million people are admitted to hospitals every year in the U.S. They come to seek treatments and get better. Unfortunately, it doesn’t always go as planned. One in 10 patients is harmed while receiving hospital care, according to a study by the World Health Organization of people living in high-income countries like the U.S.

By examining hospital records from the Centers for Disease Control & Prevention (CDC), National Institutes of Health (NIH), the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services, and Medicare, we’ve put together this list of 10 patient safety risks to look out for, plus some suggestions to help reduce their likelihood of coming up.

Risk #1: Bloodborne Pathogens

What It Is

Bloodborne pathogens are infectious microorganisms that live in human blood, bodily fluids, organs, and tissues. The most well-known are Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus (HIV). According to the NIH, people can become infected if they’re pricked with contaminated needles or sharps or if they somehow get infected bodily fluids in their eyes, nose, or mouth (e.g., rubbing your eyes with contaminated hands).

Why It Matters

Anyone who works in an industry where they’d be exposed to human blood or “other potentially infectious material” (OPIM) is most at risk of becoming infected by bloodborne pathogens. Safetec of America, Inc. put together a list of these occupations, which includes emergency medical service providers (e.g., EMTs, paramedics), healthcare employees in clinics and physicians’ offices (e.g., nurses, physicians, PAs), and even housekeepers in healthcare facilities.

What You Can Do

If you work for a facility that has its own exposure control plan (ECP), OSHA encourages you to take some time to review the protocol your employer put in place for preventing and/or handling exposure incidents. The American Red Cross also has resources for avoiding and responding to bloodborne pathogen exposures.

Risk #2: Catheter-Associated Urinary Tract Infection (CAUTI)

What It Is

A CAUTI is an infection in any part of the urinary system (i.e., urethra, bladder, ureters, and kidneys) that’s caused by prolonged urinary catheter use.

“Catheter care is one very challenging area for healthcare providers,” said Nick Jacobs, senior partner at Senior Management Resources in Pittsburgh and founder of the Clinical and Translational Genome Research Institute. “UTIs are always a risk, and proper care of a catheterized patient is always an ongoing challenge.”

Why It Matters

The CDC notes that 75% of all hospital-acquired UTIs are associated with catheters. In fact, CAUTIs are the most common type of healthcare-related infection in the U.S. It’s estimated that there are 449,334 such events every year, and that they’ve been responsible for more than 13,000 deaths annually.

What You Can Do

Since catheters are necessary for treating a variety of conditions, the CDC published a guide for preventing CAUTIs. Generally, the CDC advises that you only use them when absolutely necessary. And, if you do need to use one, make sure to remove it as soon as possible.

Risk #3: Diagnostic Errors

What It Is

The National Academy of Medicine defines a diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” According to the Society to Improve Diagnosis in Medicine (SIDM), these errors fall into one of three categories:

1. A delayed diagnosis (i.e., a diagnosis should’ve been made earlier);
2. A wrong diagnosis;
3. A missed diagnosis;

“Because hospitals are so comprehensively equipped with imaging and laboratory equipment, diagnosing patients becomes more of an interpretative skill than a visceral or intellectual challenge,” said Jacobs. “Unfortunately, if the doctor utilizes only the numbers and ignores the patient, sometimes the diagnosis can be missed. If you don’t ask the right questions, you may not get the answer that is the missing puzzle piece.”

Why It Matters

Diagnostic errors have the potential to throw off every aspect of a patient’s care plan. For example, a cancerous tumor that’s mistaken for a boil or misdiagnosed as an ulcer can metastasize before the patient receives proper treatment. These types of errors can also lead to patients receiving treatments that may worsen their condition. The National Academy of Medicine notes that diagnostic errors are responsible for about 10% of patient deaths each year.

Medical errors are now the third leading cause of death in the U.S. An eight-year study by Johns Hopkins revealed that more than a quarter of a million deaths occur every year that can be attributed to mistakes in medical care. Only heart disease and cancer are responsible for more deaths.

What You Can Do

The World Health Organization (WHO) published a comprehensive guide on how to prevent diagnostic errors, as well as what to do if a mistake is made. The National Academy of Medicine suggests 10 ways healthcare professionals can help reduce diagnostic errors. Here are a few examples:

• Be an advocate for your patients and their needs.
• Facilitate communication between patients and their care teams.
• Provide your patients with the support they need if they receive a bad diagnosis or if the diagnosis isn’t yet determined.
• Act as the eyes and ears of the diagnostic teams, and make sure to monitor your patients’ responses to treatment.

Risk #4: Hacked Medical Devices

What It Is

Today, more medical devices than ever are connected to the internet. Connected devices have proven to be a vital tool for monitoring conditions and treatments, but have also been targeted by cybercriminals. Glucometers, heart rate monitors, MRIs, and implanted electronic devices, such as pacemakers, have been hacked.

Cyberattacks on hospitals have become more common in the past year. In 2020, more than 46 hospitals and healthcare systems were hit in just one attack, exposing millions of patients’ records.

Why It Matters

There are three significant concerns created by these additional threat risks:

1. Data Breaches: Hackers and cybercriminals might gain access to patients’ sensitive health and financial information.
2. Malware/Ransomware: Hackers could use these devices as entry points into the hospital’s main network and inject malware or ransomware. In late 2020, the Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the Department of Health and Human Services (HHS) put out a rare joint statement warning about increased ransomware attacks on hospitals.
3. Changes to Device Behavior: Hackers would have the ability to influence a device’s behavior, which could interrupt the patient’s care and cause them serious harm. In 2007, former Vice President Dick Cheney received a new pacemaker and asked the manufacturer to disable its WiFi for this very reason.

What You Can Do

In its ”Report on Improving Cybersecurity in the HealthCare Industry,” the U.S. Department of Health and Human Services urges all healthcare employees to educate themselves on healthcare cybersecurity risks and best practices. With an increased level of awareness, health providers can put themselves in a better position to not only protect their patients, but also to identify potential warning signs in devices’ behaviors and report those issues to the right people at the right time—whether it’s to a superior or the IT department. The American Nurses Association (ANA) also published tips for nurses to support their organization’s cybersecurity efforts. Here are some examples:

• Choose a secure password and don’t share it with anyone.
• Delete emails, messages, and attachments from unknown sources.
• Use data encryption for all your devices.
• Report any concerns or problems you may have to your IT department.

Risk #5: Healthcare-Associated Venous Thromboembolism (HA-VTE)

What It Is

Venous thromboembolism (VTE) is when a blood clot forms in a vein. If left untreated, the clot can break free and lodge itself in the arteries of the lungs, which would block oxygen from getting into the blood. The CDC defines healthcare-associated VTE as a blood clot that occurs “as a result of hospitalization, surgery, or other healthcare treatment or procedure.”

Why It Matters

The CDC estimates that VTE affects about 900,000 people every year in the U.S. and results in about 100,000 early deaths. Additionally, about one in 10 hospital deaths are attributed to blood clots in the lungs. To that point, the International Society on Thrombosis and Haemostasis (ISTH) notes that “60% of all VTE cases occur during or within 90 days of hospitalization, making it a leading preventable cause of hospital death.”

What You Can Do

Find out if your healthcare facility has a VTE protocol in place. If it does, familiarize yourself with the guidelines and encourage your colleagues to do the same. You can also review the comprehensive guide on preventing hospital-associated VTE from the Agency for Healthcare Research and Quality (AHRQ).

“Thromboembolism killed my grandfather, my grandmother, and caused my daughter’s father-in-law to lose his leg above the knee,” said Jacobs. “Comprehensive measures are taken with special air mattresses, leg devices, medication, etc. to assist in preventing these blood clots. The biggest challenge here is vigilance.”

Risk #6: Hospital-Acquired Pneumonia

What It Is

Every day, one out of every 31 patients in U.S. hospitals has at least one infection that’s associated with their hospital care, according to the CDC. These Healthcare-Associated Infections (HAIs) range from minor infections to pneumonia to fatalities.

Hospital-acquired pneumonia is a lung infection that’s acquired during a patient’s hospital stay. It usually comes on if they’ve been at the hospital more than two days and accounts for nearly 15% of all HAIs with a high mortality rate.

Why It Matters

Hospital-acquired pneumonia can be far more serious than community-acquired pneumonia and can even be fatal. Hospital patients are already sick, so their bodies have a harder time fighting off illness. Additionally, germs found in hospitals can be more dangerous because they’re more resistant to antibiotics than those found elsewhere.

What You Can Do

The CDC published an extensive resource on preventing the spread of pneumonia, and the NIH shared a list of actions you can take to prevent spreading pneumonia to your patients. Here are some examples:

• Wash your hands regularly and for the proper amount of time.
• Make sure to use hand sanitizer when appropriate.
• Always wear gowns during patient visits.
• Elevate the head of the patient’s bed so they can breathe more easily.
• Never skip patients’ basic oral care procedures. This can help reduce the number of microbes in their mouth that they can then breathe into their lungs.

Risk #7: Medication Errors

What It Is

The National Council for Medication Error Reporting and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.” Medcom provided a list of common types of medication errors, which include:

• Prescribing the wrong drug, given the patient’s medical history
• Missing or skipping a dose of a medication
• Administering a drug outside the predetermined interval of time
• Delivering a higher or lower dose of a drug than was prescribed
• Administering the medication through the wrong route
• Incorrectly formulating or compounding a medication

Medication errors in hospitals are more common than you might think. However, just 1% of medication errors result in harm to patients.

“In the inpatient setting, the most common medication errors are errors in dosage calculation and inappropriate preparation of the medication,” said Rachel Kia, BSN, RN, CMSRN. “Barcode scanners are an incredible innovation for preventing these kinds of errors.”

Errors related to inappropriate preparation of the medication are a bit harder to circumvent.

Kia provided this example: “25mg of a medication needs to be given to the patient, but the tablet comes in 50mg. This requires the nurse to cut the tablet in half prior to administering it to the patient. This step can easily be missed if the final verification is not performed at the bedside, or bypassed because the system does not generate an error message when the 50mg tablet is scanned.”

Why It Matters

According to the Agency for Healthcare Research & Quality (AHRQ), adverse drug events account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year, and about half of them are preventable. These errors could not only prevent patients from receiving proper treatment, but could also prove to be fatal.

What You Can Do

Both the FDA and the WHO published useful guidelines for reducing medication errors and improving patient safety. Their suggestions include:

• Familiarizing yourself with the medication procedures that your hospital, facility, or clinic has put in place
• Double- and triple-checking dosages before administering medication
• Matching the patient’s name and ID to the medication you’re administering
• Being aware of the patients’ conditions and allergies
• Documenting every action you take before, during, and after administering treatment

Risk #8: Methicillin-Resistant Staphylococcus Aureus (MRSA)

What It Is

According to the Mayo Clinic, MRSA (Staphylococcus aureus) is an infection that’s “caused by a type of staph bacteria that’s become resistant to many of the antibiotics used to treat ordinary staph infections.” The CDC adds that it can be spread through direct contact with an infected wound or contaminated hands.

“MRSA is an ongoing challenge,” said Jacobs. “Patients are now tested when they enter the hospital and are appropriately isolated if they show signs of MRSA. The housekeeping staff is carefully trained to sanitize and clean every surface meticulously, and care providers gown and glove appropriately.”

Although MRSA infections have reduced in the past few years, there were more than 323,000 cases in the most recent reporting year and 10,600 deaths.

Why It Matters

MRSA is very easy to spread and can cause infections in your bloodstream, heart, lungs, bones, and joints. If left untreated, MRSA can become life-threatening.

What You Can Do

MRSA can be difficult to prevent completely, but you can reduce your patients’ chances of contracting it by administering antibiotics both before and after surgery. Following surgery, wash your hands thoroughly before you touch the patient, and make sure that visitors wash their hands, too. The CDC published its guidelines for preventing the spread of MRSA in hospitals.

Risk #9: Post-Discharge Adverse Events

What It Is

A post-discharge adverse event is any injury a patient sustains after they’ve been discharged that is a direct result of the care they received. Typically, this type of adverse event occurs about one month after discharge and usually results in the patient being readmitted to the hospital. There are several complications that can happen post-discharge. The most common are hospital-acquired infections and medication errors.

Why It Matters

According to the AHRQ, about 20% of patients experience complications within three weeks of being discharged from the hospital—and 61% of those are considered to be preventable issues.

What You Can Do

The AHRQ recommends not discharging patients while test results are pending, since those results may indicate that the patient requires further hospital care. You should also ensure that the patient understands their own discharge plan, including what medications they’re taking and the correct dosages for each. Another great resource is the Family Caregiver Alliance, which has published information on how to build discharge plans, as well as tips on what families and caregivers can do to guarantee a smooth discharge process.

Risk #10: Sepsis

What It Is

The CDC explains that sepsis is “the body’s extreme response to an infection.” Specifically, it causes inflammation and, if left untreated, can lead to organ failure, tissue damage, and even death. Any type of infection can cause sepsis, no matter whether it’s bacterial, viral, fungal, or parasitic.

Why It Matters

More than 1.7 million Americans get sepsis each year, and about 270,000 die from it annually. Additionally, one in three patients who die in hospitals have sepsis. It’s particularly dangerous for older adults and those with weakened immune systems.

What You Can Do

Becker’s Hospital Review collected strategies for tackling sepsis from a group of healthcare professionals. One easy thing you can do to prevent your patients from developing sepsis is to make sure their infections are being treated properly and promptly. If any patients have open wounds, be sure to clean them regularly. The Sepsis Alliance also recommends that everyone wash their hands frequently and follow proper handwashing procedures. It’s a simple task, but it will help prevent you from inadvertently spreading infections or illnesses to other patients.

Final Thoughts

Whether you’re in school to become a healthcare provider or a seasoned pro, you know how crucial risk management is in your industry. Carefully planning for risks allows you to provide your patients with the high-quality care they deserve while keeping them safe. If you’d like to learn more about things you can do to help increase patient safety within your organization, make sure to check out these articles:

• The Berxi Guide to Risk Management in Healthcare
• Improving Patient Safety in Nursing: 7 Tips Nurses Can Start Implementing Today
• The 8 Most Common Nursing Mistakes
• 5-Minute Summary: What Is a HIPAA Violation?
• HIPAA & Social Media: What You Can & Can’t Post If You Work in Healthcare

 

Originally written by Michael Walton on September 17, 2018.
Updated by Paul Dughi on June 18, 2021.

 

Image courtesy of iStock.com/Tempura

 

Last updated on Jul 24, 2024.
Originally published on Jun 18, 2021.

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