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Adverse events happen. ECRI Institute PSO creates opportunities to reduce these unfortunate events. It’s not just the information put into our PSO, it’s the information, analysis, advice, and support that allows participants to prevent future occurrences and learn from other healthcare organizations that makes working with a PSO so impactful.

The following examples show how ECRI Institute PSO creates and disseminates information based on the confidential data reported to the PSO to promote organizational learning and promote good patient safety practices:

Top 10 Patient Safety Concerns

Patient safety is a top priority for every healthcare organization, but knowing where to direct patient safety initiatives can be a daunting task.

To help guide organizations in deciding where to focus their patient safety efforts, ECRI Institute has developed the 2016 Top 10 Patient Safety Concerns for Healthcare Organizations.

Click here to read our Top 10 Patient Safety Concerns for 2015 or view a YouTube video on the 2015 Top 10. Our 2014 Top 10 Patient Safety Concerns article is also available.

Partnership for Health IT Patient Safety

The Partnership for Health IT Patient Safety has established workgroups for in-depth study of health IT events. The issue of copying and pasting health information (e.g., orders, notes, labels) was chosen for the first workgroup. Copy and paste is widespread, often underreported, and has the potential to cause adverse patient safety events. Tools released as a result of this effort include:

Health IT Patient Safety Update newsletters are also released by the partnership throughout each year:

Proceedings from the annual meetings of the partnership are also available:

 Public Resources from ECRI Institute PSO

 

 

Potential HIPAA Violations Result in $5.5 Million Settlementhttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts022217_Potential.aspxPotential HIPAA Violations Result in $5.5 Million Settlement2017-02-22T00:00:00ZA healthcare system in south Florida has paid $5.5 million to the U.S. Department of Health and Human Services (HHS) to settle potential violations of the Health Insurance Portability and Accountability Act privacy and security rules, reports HHS's Office for Civil Rights (OCR).
Can a Rude Physician Hurt More than a Patient’s Feelings?https://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts022217_Rude.aspxCan a Rude Physician Hurt More than a Patient’s Feelings?2017-02-22T00:00:00Z​Patients treated by surgeons who generate a large number of unsolicited patient observations are 14% more likely to experience postoperative complications than those treated by surgeons with fewer complaints against them, according to a February 15, 2017, original investigation published in JAMA Surgery.
Usability Testing Confirms Partnership’s Copy-and-Paste Safety Recommendationshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts021517_Usability.aspxUsability Testing Confirms Partnership’s Copy-and-Paste Safety Recommendations2017-02-15T00:00:00Z​Usability testing "overwhelmingly" supports recommendations for safe use of copy and paste in electronic health records (EHRs) made by the Partnership for Health IT Patient Safety, according to a January 2017 National Institute for Standards and Technology (NIST) report.
State Apology Laws May Not Reduce Risk of Liabilityhttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts021517_Apology.aspxState Apology Laws May Not Reduce Risk of Liability2017-02-15T00:00:00Z​State apology laws that prohibit using a physician's apology against him or her in a malpractice lawsuit do not reduce risk of medical malpractice liability, according to a Vanderbilt University study published on December 12, 2016.
During Labor, Maternal Satisfaction Not Dependent on Analgesic Effectiveness Alonehttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts020817_Labor.aspxDuring Labor, Maternal Satisfaction Not Dependent on Analgesic Effectiveness Alone2017-02-08T00:00:00Z​Although its analgesic effectiveness varied, the use of nitrous oxide during labor resulted in high patient satisfaction scores, suggesting that satisfaction with labor analgesia is not determined solely by the level of pain relief achieved, according to a study published in the February 2017 issue of Anesthesia & Analgesia.
Transgender Man’s Case in Limbo as Supreme Court Rules on ACA’s Nondiscrimination Clausehttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts020817_Transgender.aspxTransgender Man’s Case in Limbo as Supreme Court Rules on ACA’s Nondiscrimination Clause2017-02-08T00:00:00Z​Allegations that a Minnesota healthcare facility violated federal nondiscrimination laws while treating a transgender man must wait to be resolved, a Minnesota district court ruled on January 30, 2017.
What Percentage of Adverse ICU Medication Events Are Related to the EHR?https://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts020117_Percentage.aspxWhat Percentage of Adverse ICU Medication Events Are Related to the EHR?2017-02-01T00:00:00Z​More than one-third of medication events in intensive care units (ICUs) may be related to the electronic health record (EHR), with the majority coming in the ordering phase, according to a study published in the January 2017 Journal of Healthcare Risk Management.
CMS Guidance Addresses Provisions for Beneficiary Notice about Observation Statushttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts020117_Observation.aspxCMS Guidance Addresses Provisions for Beneficiary Notice about Observation Status2017-02-01T00:00:00Z​By early March, all hospitals, including critical access hospitals, must provide Medicare beneficiaries who receive observation services as outpatients for more than 24 hours a written and oral explanation of the services.
Better Together: Combine Teamwork Training and Systems Interventions to Improve Safetyhttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts012517_Better.aspxBetter Together: Combine Teamwork Training and Systems Interventions to Improve Safety2017-01-25T00:00:00Z​Initiatives that combine teamwork training and systems interventions are more effective than implementing either approach alone, according to a study published in the January 2017 Annals of Surgery.
Updated Sepsis Guidelines Call for Performance Improvement Programs, Other Changes https://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts012517_Updated.aspxUpdated Sepsis Guidelines Call for Performance Improvement Programs, Other Changes 2017-01-25T00:00:00Z​Performance improvement initiatives targeting sepsis are associated with improved patient outcomes, state the authors of the Surviving Sepsis Campaign (SSC) 2016 Guidelines for Management of Sepsis and Septic Shock; the guidelines were recently published in Intensive Care Medicine and Critical Care Medicine.
Hospital Patient Satisfaction Has Improved “Modestly”; Value-Based Purchasing Not the Cause, Say Study Authorshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts011817_Satisfaction.aspxHospital Patient Satisfaction Has Improved “Modestly”; Value-Based Purchasing Not the Cause, Say Study Authors2017-01-18T00:00:00Z​In U.S. hospitals, patient experience improved "steadily but modestly" from 2008 through 2014, but researchers found no evidence that the Centers for Medicare and Medicaid Services' (CMS) Value-Based Purchasing (VBP) program "led to meaningful gains in patient experience," states a study in the January 2017 issue of Health Affairs.
A $475,000 Late Fee: OCR Settles First Case for Lack of Timely Breach Reportinghttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts011817_Late.aspxA $475,000 Late Fee: OCR Settles First Case for Lack of Timely Breach Reporting2017-01-18T00:00:00Z​The first Health Insurance Portability and Accountability Act (HIPAA) settlement for lack of timely notification about a breach of unsecured protected health information (PHI) was announced on January 9, 2017, by the U.S. Department of Health and Human Services' Office for Civil Rights (OCR).
How Well Do Patients Understand Life-Sustaining Treatment Orders?https://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts011117_LifeSustaining.aspxHow Well Do Patients Understand Life-Sustaining Treatment Orders?2017-01-11T00:00:00Z​Patients and their proxies "may believe that…documenting some, but not all, of their wishes on the MOLST [medical orders for life-sustaining treatment] form is sufficient for directing their end-of-life care," write researchers in a January 2017 Journal of the American Medical Directors Association article.
Joint Commission Seeking Input on Proposed Revisions to Pain Assessment and Management Standardshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts011117_joint.aspxJoint Commission Seeking Input on Proposed Revisions to Pain Assessment and Management Standards2017-01-11T00:00:00Z​The Joint Commission is seeking input on proposed revisions to its Requirements Related to Pain Assessment and Management for the Hospital Accreditation Program, the organization announced on January 9, 2017.
Ask HRC: Protecting against Falls in the Bathroomhttps://www.ecri.org/components/HRC/Pages/AskHRC010917.aspxAsk HRC: Protecting against Falls in the Bathroom2017-01-09T00:00:00Z​​​An HRC member recently wrote asking for guidance on preventing falls in bathrooms in inpatient or residential treatment facilities. Specifically, the member sought guidance on limiting environmental factors that may contribute to increased fall risk.

 Other Resources from ecri institute pso

PSO Navigator newsletters, Deep Dive reports, and Patient Safety E-Lerts are also being made publicly available to further our mission to improve patient safety:

Help Make Your Patients Safer

See how ECRI Institute's PSO Plus can help you and your organization meet your goals. Call (610) 825-6000, ext. 5558 or e-mail pso@ecri.org.