PLYMOUTH MEETING, PA—Poorly coordinated care puts patients at risk for preventable events, such as medication errors, lack of necessary follow-up care, and diagnostic delays and errors. These events can lead to repeat testing and procedures, dissatisfying care experiences, preventable patient harm, and unnecessary hospital readmissions.

ECRI Institute Patient Safety Organization (PSO), with experience analyzing more than 2 million adverse events and near misses, focused its just-released 4th annual Deep Dive™ on care coordination issues affecting patients primarily during an inpatient hospital admission and at discharge.

"Coordinating a patient's care among various providers and across multiple care settings—from a hospital to a rehabilitation facility to the patient's home, or from a hospital to a skilled nursing facility—is a huge challenge," says William M. Marella, MBA, ECRI Institute executive director of PSO Operations & Analytics. "Several events from the analysis were particularly compelling in illustrating the importance of ensuring that providers along the care continuum work together as a team and communicate among each other about the patients' care."

ECRI Institute PSO found that the largest share of all the care coordination reports—whether inpatient- or discharge-related events—involved medications or medication reconciliation failures. Laboratory testing and diagnostic imaging incidents contributed to 20% of the inpatient care coordination events. The top four contributing factors were:

  • human factors
  • communication breakdowns
  • policies and procedures that were either unclear or not in place
  • limitations in staff qualifications

ECRI Institute PSO analyzed 223 events reported by 38 facilities over three and a half years, starting in September 2011 and ending in mid-January 2015.

The ECRI Institute PSO Deep Dive: Care Coordination executive summary is available for free download. The full report is available to all ECRI Institute PSO and partner PSO members and is available for purchase by non-members. Additional information will be presented in ECRI Institute PSO's Monthly Brief free e-newsletter; go to to sign up.

For questions about this topic, or for information about purchasing the report, please contact ECRI Institute PSO by telephone at (610) 825-6000, ext. 5558; by e-mail at; by fax at (610) 834-1275; or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.


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About ECRI Institute

ECRI Institute (, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research to healthcare to discover which medical procedures, devices, drugs, and processes enable improved patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. Strict conflict-of-interest guidelines ensure objectivity. ECRI Institute is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute PSO is listed as a federally certified Patient Safety Organization by the U.S. Department of Health and Human Services. Find ECRI Institute on Facebook ( and on Twitter (

For more information, contact:

Laurie Menyo, Director of Public Relations and Marketing Communications
(610) 825-6000, ext. 5310