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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

 

 

Persistent Opioid Use Associated More with Patient Factors than Post-Surgical Painhttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts041917_Opioid.aspxPersistent Opioid Use Associated More with Patient Factors than Post-Surgical Pain2017-04-19T00:00:00Z​Patients continue to use opioids after surgery for complex reasons that go beyond surgical pain, state the authors of an original investigation published in JAMA Surgery. Citing wide variation and frequent excess in perioperative outpatient opioid prescribing, the authors conducted a population-based study of 36,177 insured individuals in the United States, examining incidence of "new persistent opioid use" (i.e., continued use at 90 days after surgery) and related risk factors for individuals undergoing minor or major surgical procedures.
CMS Issues Proposed FY 2018 Payment and Policy Updateshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts041917_FY.aspxCMS Issues Proposed FY 2018 Payment and Policy Updates2017-04-19T00:00:00Z​The Centers for Medicare and Medicaid Services (CMS) on April 14, 2017, issued a proposed rule to its hospital inpatient prospective payment system that should increase payments by approximately 1.7% in fiscal year (FY) 2018 after accounting for inflation and other required adjustments.
Device Cybersecurity: The Importance of Being Proactivehttps://www.ecri.org/components/HRC/Pages/ASG041217.aspxDevice Cybersecurity: The Importance of Being Proactive2017-04-12T00:00:00Z​News of healthcare cybersecurity breaches—some of which compromised tens of thousands of patient medical records—continues to dominate headlines, leaving many hospitals wondering whether they would be prepared in the event of an attack.
Decrease Potential for “Oh, by the Way” Moments with Pre-Visit Notes from Patientshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts041217_OhByTheWay.aspxDecrease Potential for “Oh, by the Way” Moments with Pre-Visit Notes from Patients2017-04-12T00:00:00Z​Giving patients the opportunity to type their own primary care visit agendas into the electronic health record improves patient-clinician communication, according to a study published in the March/April 2017 Annals of Family Medicine.
We Didn’t Know the Cookies Had Marijuana in Them, Say Hospital Employeeshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts041217_Marijuana.aspxWe Didn’t Know the Cookies Had Marijuana in Them, Say Hospital Employees2017-04-12T00:00:00Z​Six workers at a North Carolina medical center claim they did not know that the cookies and muffins they ate at work had marijuana in them, according to an April 4, 2017, article in the Stateville Record & Landmark.
Eleven Ways Leadership Can Commit to Reducing Physician Burnouthttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts040517_Eleven.aspxEleven Ways Leadership Can Commit to Reducing Physician Burnout2017-04-05T00:00:00Z​Leadership in healthcare organizations must embrace their role in preventing physician burnout, say the chief executive officers (CEOs) of 10 healthcare organizations in a March 28, 2017, blog post at Health Affairs.
No Substitute for Experience When it Comes to Caring for Frail Surgical Patientshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts040517_Substitutes.aspxNo Substitute for Experience When it Comes to Caring for Frail Surgical Patients2017-04-05T00:00:00Z​Experience matters when it comes to caring for frail surgical patients, say the authors of a study published in the April 2017 issue of Anesthesiology.
Longer Initial Hospital Stays Could Cut Down on Seven-Day Readmissions from PAC Facilitieshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts032917_Longer.aspxLonger Initial Hospital Stays Could Cut Down on Seven-Day Readmissions from PAC Facilities2017-03-29T00:00:00Z​Shorter initial hospital stays may result in an increased risk of readmission to hospitals from postacute care (PAC) facilities among older or frail patients, according to a clinical investigation published in the February 2017 issue of the Journal of the American Geriatrics Society.
The Data Breach May Be Coming from Inside the Organizationhttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts032917_Data.aspxThe Data Breach May Be Coming from Inside the Organization2017-03-29T00:00:00Z​Almost 60% of healthcare data breaches reported in February 2017 came from individuals within the affected organizations, according to a March 20, 2017, article in Healthcare Informatics.
Study Finds Many Failure-to-Rescue Events Are Not Preventablehttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts032217_Rescuse.aspxStudy Finds Many Failure-to-Rescue Events Are Not Preventable2017-03-22T00:00:00Z​A study published in the March issue of Surgery found that many failure-to-rescue (FTR) events—deaths that occur after a complication—are not preventable, calling into question whether failure to rescue, as defined, is appropriate to use as a metric for quality of care.
GAO: HHS Should Assess Efforts to Increase Patient Access to Electronic Health Informationhttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts032217_GAO.aspxGAO: HHS Should Assess Efforts to Increase Patient Access to Electronic Health Information2017-03-22T00:00:00Z​Despite efforts by the U.S. Department of Health and Human Services (HHS) to enhance patients' access to their electronic health information, data from 2015 show that relatively few patients take advantage of the access, according to a March 2017 report from the U.S. Government Accountability Office (GAO).
Two Studies Look at the Effectiveness of Efforts to Reduce Hospitalizationshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts031517_Two.aspxTwo Studies Look at the Effectiveness of Efforts to Reduce Hospitalizations2017-03-15T00:00:00Z​Strategies to reduce hospitalizations were the focus of a pair of articles in the March 2017 issue of Health Affairs.
CMS Issues FAQ about Medicare Outpatient Observation Noticehttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts031517_CMS.aspxCMS Issues FAQ about Medicare Outpatient Observation Notice2017-03-15T00:00:00Z​The Centers for Medicare and Medicaid Services (CMS) has provided additional guidance to hospitals on providing a Medicare Outpatient Observation Notice (MOON) to Medicare beneficiaries who receive observation services as outpatients for more than 24 hours.
Joint Commission Outlines 11 Tenets of a Safety Culturehttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts030817_Joint.aspxJoint Commission Outlines 11 Tenets of a Safety Culture2017-03-08T00:00:00Z​Failure by leadership to create an effective safety culture is a contributing factor to many types of adverse events, said Joint Commission in a March 1, 2017, Sentinel Event Alert.
New Model Mimics the Spread of Multidrug-Resistant Pathogens Rising from Sink Drainshttps://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts030817_Model.aspxNew Model Mimics the Spread of Multidrug-Resistant Pathogens Rising from Sink Drains2017-03-08T00:00:00Z​Increasing reports have linked colonized sink traps to nosocomial infections, but the mechanism of transmission has been unclear.

 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.