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11 PATIENT SAFETY PRIORITIES IN 2017 ECRI Names 10 Health Technology Hazards for 2017 — Infusion Errors, Scope Cleaning Top List By Heather Punke E CRI Institute released its "Top 10 Health Technology Hazards for 2017" report in November, featur- ing an array of issues, including infusion errors, inadequate cleaning of complex reusable instruments and infections linked with heater-cooler devices. "Technology safety can often be over- looked when hospital leaders are deal- ing with so many other issues," said Da- vid Jamison, executive director of ECRI Institute's health devices group. "As an independent medical device testing laboratory and investigator of technolo- gy-related incidents, we know what can go wrong and what steps hospitals can take to reduce patient harm related to specific technologies and process." ECRI Institute's health devices group puts together this list annually, evaluat- ing neither the most frequently reported problems nor the ones that have the most severe consequences, but rather the ones the group believes should have the high- est priority currently. The following are ECRI Institute's 10 picks for top health technology hazards for 2017. 1. Infusion errors, like IV free flow, re- sulting from overlooked simple safety steps 2. Inadequate cleaning of complex re- usable instruments 3. Missed ventilator alarms 4. Undetected opioid-induced respira- tory depression 5. Infection risks raised by heater-cool- er devices used during cardiothoracic surgery 6. Software management gaps 7. Occupational radiation hazards in hy- brid ORs 8. Automated dispensing cabinets use and setup errors 9. Surgical stapler misuse and malfunc- tion 10. Device failures caused by cleaning products and practices n Redefining Patient Safety in 2017 — 6 Thoughts From IHI CEO Derek Feeley By Heather Punke A lthough much progress was made in terms of patient safety in 2016, there is still much more work to be done in 2017 and beyond, according to Derek Feeley, president and CEO of the Institute for Healthcare Improvement. "Let's recognize the progress that we've made…but there's absolutely no room for complacency," he said during a Dec. 6 keynote speech at the IHI National Forum on Quality Improvement in Health Care in Orlando, Fla. In fact, he cited the 2016 study that indicates medical errors are one of the leading causes of death in the U.S. as a clear example that more work is necessary to prevent patient harm. Mr. Feeley urged healthcare executives to change the patient safety par- adigm as part of their New Year's resolutions for 2017, and laid out six ways to do so. 1. Think about how to make as many things as possible go right, as well as how to minimize the number of things that go wrong. Learning from mistakes is important, but it is not sufficient to rely on hindsight alone. "We don't have to fail in order to learn," Mr. Feeley said. He encouraged provider organizations to learn from and build on successes instead of solely focusing on correcting failures. 2. Change from reactive to proactive. Mr. Feeley used a lake ice analogy to illustrate his point. "We're spending too much time measuring the number of people who fall through the ice — we should be monitoring the thickness of the ice," he said. In addition to asking themselves if care was safe yesterday, leaders should also ask themselves if their hospitals' care was safe today and if it will be safe tomorrow. 3. Think about patient safety systems, not only patient safety projects. While there will always be room for safety improve- ment projects, some safety issues cannot be solved by singular projects, according to Mr. Feeley. Additionally, focusing on one safety problem at a time allows others to crop up. Instead, hospitals should create feed- back loops so every improvement project builds on the other, until safety is viewed through a system lens instead of an individual project lens. "My proposal is that we invest in safety systems rather than safety whack-a-mole," he said. 4. Move from fear, blame and liability to humility, trust and transparency. Provider organizations need to have a culture in place that encourages reporting of adverse events and near misses and protects those who report them. Stealing a concept from a flight crew, Mr. Feeley said, "A mistake is not always a failure, but not reporting one could be." 5. Make patient safety an inclusive initiative. "e people who are most invested in patient safety are the patients themselves," Mr. Fee- ley said, and healthcare in the U.S. needs to make it easier for patients to participate in their own care and safety. He referenced an initiative from the Canadian Patient Safety Institute called #AskListenTalk, encourag- ing patients to ask questions about their care and safety, and said such initiatives should be imported to the U.S. 6. Broaden the definition of harm. While infections and wrong- site surgeries are clear examples of patient harm, Mr. Feeley proposed expanding the definition of harm to include lack of humanity and dig- nity. For instance, when providers fail to introduce themselves to a pa- tient, it can make the patient feel helpless and less than human. "No one should ever feel like just a…body in a hospital bed," Mr. Feeley said. "Absence of dignity is harm." n