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Not Just Well-Known Adverse Events: ECRI Institute Shares Bigger Picture from Four Years as a Patient Safety Organization
By: PR Newswire
Jan. 7, 2013 11:26 AM
ECRI Institute PSO offers free report on trends from analysis of more than 100,000 reported events
PLYMOUTH MEETING, Pa., Jan. 7, 2013 /PRNewswire-USNewswire/ -- Patient Safety Organizations (PSOs) permit healthcare providers to report adverse events under legal protection and are a rich source of important information that can be put into practice. With nearly four years' experience reviewing patient safety data, ECRI Institute PSO is now releasing important trends and guidance that can be used to reduce injury and deaths. Click here to read the report.
Some of the trends identified by ECRI Institute PSO have been expected. For example, of the more than 108,000 adverse events reported to ECRI Institute PSO since 2009, half have been related to one of three topics: medication or other substance errors, falls, or laboratory tests and noninvasive procedures. These high-risk, high-frequency events were well known long before the Patient Safety and Quality Improvement Act (PSQIA) was signed into law in 2005.
"The real power of PSOs lies in their ability to see the bigger picture beyond the raw numbers—by looking at narratives, best practices research, and other PSO submissions such as root cause analyses," says Barbara Rebold, director of operations, ECRI Institute PSO. "By examining aggregated and rare events, ECRI Institute believes that PSOs can help organizations identify and understand the process issues that lead to adverse events."
"After an event has occurred, organizations rarely look at prior similar events from their own or other reporting systems," says Karen P. Zimmer, MD, MPH, medical director, ECRI Institute PSO. "A review of past events can seem cumbersome in the aftermath of an adverse outcome, when there may be significant urgency to resolve the current situation. But that review can shed important light on the current investigation at the same time as it can help shape future improvements. Our analysis should help them do this efficiently."
ECRI Institute is sharing this special report with the healthcare community as part of its mission to improve patient care. This report, previously available for members only, is from the Healthcare Risk Control System—a resource included with ECRI Institute PSO Plus membership.
Learnings from ECRI Institute PSO are published to its members and also through brief articles in the free eNewsletter, PSO Monthly Brief. To sign up for the PSO Monthly Brief, go to www.ecri.org/psobrief.
For information about ECRI Institute PSO, contact ECRI Institute by telephone at (610) 825-6000, ext. 5558; by e-mail at firstname.lastname@example.org; by fax at (610) 834-1275; or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.
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