ECRI Institute PSO Analyzes Data from More Than 100,000 Adverse Events

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 has released 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.”

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.

About ECRI Institute
For 45 years, ECRI Institute’s work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit www.ecri.org. Find ECRI Institute on Facebook (www.facebook.com/ECRIInstitute) and Twitter (www.twitter.com/ECRI_Institute).