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It’s not just the information you put into a 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 ECRI Institute 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.

ECRI Institute PSO Deep Dives

Each year ECRI Institute PSO completes a Deep Dive analysis of a patient safety topic. These reports are benefits of membership in the PSO. Examples available to the public are provided below:  

Top 10 Patient Safety Concerns

To help guide organizations in deciding where to focus their patient safety efforts, ECRI Institute has developed the 2017 Top 10 Patient Safety Concerns for Healthcare Organizations. The Top Concerns are derived from many sources including the events reported to ECRI Institute PSO.

Past editions of the Top 10 Patient Safety Concerns:

Partnership for Health IT Patient Safety

The Partnership for Health IT Patient Safety is a multi-stakeholder collaborative whose goal is to make health information technology (IT) safer together. ECRI Institute PSO facilitates event reporting and analysis for the Partnership. Resources from the Partnership are available to the public.

 Public Resources from ECRI Institute PSO

 

 

What You Don’t See Can Hurt You: Diagnostic Errors in Radiologyhttps://www.ecri.org/components/PSOCore/Pages/e-lert050917.aspxWhat You Don’t See Can Hurt You: Diagnostic Errors in Radiology2017-05-09T00:00:00Z Incorrect or delayed diagnosis in radiology can result in a delay in treatment, incorrect or inappropriate treatment, or other complications. ECRI Institute PSO analyzed a sample of 231 events related to various components of the communication, prioritization of testing, and reporting of radiology tests.
If It’s Not Clean, It’s Not Sterile: Reprocessing Contaminated Instrumentshttps://www.ecri.org/components/PSOCore/Pages/e-lert041117.aspxIf It’s Not Clean, It’s Not Sterile: Reprocessing Contaminated Instruments2017-04-11T00:00:00Z ​The failure to adequately reprocess contaminated instruments—that is, not cleaning and disinfecting or sterilizing them—before using them on subsequent patients can lead to the spread of deadly pathogens.
Implementing the ENFit Initiative for Preventing Enteral Tubing Misconnectionshttps://www.ecri.org/components/PSOCore/Pages/e-lert032917.aspxImplementing the ENFit Initiative for Preventing Enteral Tubing Misconnections2017-03-29T00:00:00Z Numerous reports describe the risks from misconnections of enteral feeding tubing (such as tubes being connected to catheters or to non-enteral tubing), sometimes with fatal outcomes. In response, there is a growing movement toward using a connector design called ENFit.
Know Your ADCs: Poor Configuration Risks Medication Errorshttps://www.ecri.org/components/PSOCore/Pages/e-lert022817.aspxKnow Your ADCs: Poor Configuration Risks Medication Errors2017-02-28T00:00:00Z ​Poor stocking or restocking practices and insufficient attention to planning when configuring an automated dispensing cabinet (ADC) have resulted in delays in patient care, the administration of incorrect medications, and the incorrect concentration of a medication that, in turn, have resulted in severe injury and the need for additional monitoring.
ECRI Institute PSO Members' Meeting: Moving Mountainshttps://www.ecri.org/components/PSOCore/Pages/2016PSOMeeting.aspxECRI Institute PSO Members' Meeting: Moving Mountains2016-09-15T00:00:00Z ​​This is the agenda and slide handouts for ECRI Institute PSO's September 15, 2016, meeting, "Moving Mountains."
Error Decision Treehttps://www.ecri.org/components/PSOCore/Pages/PSOPol1.aspxError Decision Tree2016-05-01T00:00:00Z ​This tool contains a sample algorithm or error decision tree to apply to any event investigation.
Top 10 Patient Safety Concerns for Healthcare Organizations, 2015https://www.ecri.org/components/PSOCore/Pages/Webinar_TopTenPatientSafetyConcerns.aspxTop 10 Patient Safety Concerns for Healthcare Organizations, 20152015-06-18T00:00:00Z ​PSO Webinar, June 18, 2015, Top 10 Patient Safety Concerns for Healthcare Organizations. This webinar reviews the 2015 ECRI Institute PSO Top 10 Patient Safety Concerns to share how improving systems and processes can reduce the risk of harms that these safety concerns identify.
Medical Devices’ Role in Causing Pressure Ulcershttps://www.ecri.org/components/PSOCore/Pages/PSONav0814.aspxMedical Devices’ Role in Causing Pressure Ulcers2014-08-01T00:00:00Z ​This issue of the national PSO Navigator reviews events of pressure ulcers caused by medical devices to identify common findings.
Patient Safety E-lerts: When Patients Leave against Medical Advicehttps://www.ecri.org/components/PSOCore/Pages/E-lert_071814.aspxPatient Safety E-lerts: When Patients Leave against Medical Advice2014-07-18T00:00:00Z ​Patient Safety E-lerts July 18, 2014
E-lert10 - When Patients Leave against Medical Advicehttps://www.ecri.org/components/PSOCore/Documents/E-Lert/E-lert10 - When Patients Leave against Medical Advice.pdfE-lert10 - When Patients Leave against Medical Advice2014-07-18T00:00:00Z ECRI Institute PSO has seen several events lately in which patients have left against medical advice due to a perceived or actual lack of communication from the hospital staff to the patient regarding the treatment plan. It was noted on these events that there was sufficient time for the staff to have intervened by addressing the patient’s concerns; yet, for various reasons, this was not done. Even if the patient cannot be convinced to stay for the completion of his or her treatment, the care team should still give the patient his or her discharge instructions and prescriptions prior to the discharge.
ECRI Institute Continues to Recommend Maximum Temperature Setting of 130 degrees Fahrenheit for Blanket Warming Cabinetshttps://www.ecri.org/components/PSOCore/Pages/PSMU040114_ecri.aspxECRI Institute Continues to Recommend Maximum Temperature Setting of 130 degrees Fahrenheit for Blanket Warming Cabinets2014-04-01T00:00:00Z ​A recent study (Kelly et al., 2013) published in the Journal of PeriAnesthesia Nursing asserts that warming blankets in cabinets set to 200°F (93°C) are safe for clinical use. ECRI Institute disagrees with the paper's finding and continues to recommend that blanket warming cabinet settings be limited to 130°F (54°C).
Patient Safety E-lerts: At the Sticking Pointhttps://www.ecri.org/components/PSOCore/Pages/E-lert_020314.aspxPatient Safety E-lerts: At the Sticking Point2014-02-03T00:00:00Z ​ECRI Institute has heard anecdotal evidence that would indicate some injuries have occurred when sharps are disposed into overfilled sharps containers.
E-lert9 - At the Sticking Point - When Sharps Safety Features Fail to Protecthttps://www.ecri.org/components/PSOCore/Documents/E-Lert/E-lert9 - At the Sticking Point - When Sharps Safety Features Fail to Protect.pdfE-lert9 - At the Sticking Point - When Sharps Safety Features Fail to Protect2014-02-03T00:00:00Z Since protective devices have become widely used, the number of reported sharps injuries has declined. However, ECRI Institute PSO has received reports on sharps injuries because of incorrect activation of the safety features, or malfunction of protective devices.
Medication Safety: Inaccurate Patient Weight Can Cause Dosing Errorshttps://www.ecri.org/components/PSOCore/Pages/PSONav0214.aspxMedication Safety: Inaccurate Patient Weight Can Cause Dosing Errors2014-02-01T00:00:00Z This issue of the national PSO Navigator summarizes the types of weight-based medication dosing errors voluntarily reported to ECRI Institute PSO’s event reporting program and recommends strategies to ensure patient weights are accurately obtained, documented, and communicated to the necessary staff involved in the patient’s care.
Patient Safety E-lerts: Prevent “Bad Blood”https://www.ecri.org/components/PSOCore/Pages/E-lert_091213.aspxPatient Safety E-lerts: Prevent “Bad Blood”2013-09-12T00:00:00Z ​ECRI Institute PSO has seen many events in which blood or a blood product must be discarded because it has been improperly stored after being dispensed from the blood bank.