ECRI Institute shares four trends and lessons learned from roughly four years running a patient safety organization in a new report.
Patient safety organizations were created to provide legal protection for healthcare professionals reporting adverse events. PSOs collect and analyze these reports and provide feedback to healthcare organizations on how to prevent adverse events in the future.
ECRI Institute PSO has been in existence for about four years. In a report called "Not Just Adverse Events: The Bigger Picture From Four Years as a PSO," ECRI Institute PSO leaders identify trends in adverse event reporting and management.
1. "RCA tunnel vision." Many organizations fail to review similar past events when conducting a root cause analysis, according to the report. In addition, many organizations do not share the results of root-cause analysis widely.
2. Patient safety culture. Patient safety culture remains crucial for sustaining patient safety improvements. A strong patient safety culture requires a combination of systems thinking and evaluation of human factors; a balance of low-, medium- and high-impact interventions; and support and communication from leaders, according to the report.
3. Slow adoption of PSOs. Some organizations are reluctant to join PSOs because they are not confident the legal protections will hold up in court, they believe PSOs are a fad or they are overwhelmed with quality reporting and related activities. However, a trial court in Kentucky upheld the legal protections in 2011 and PSOs can lessen the burden of reporting, according to the report.
4. PSO visibility. Despite some organizations' reluctance to participate in a PSO, PSOs are becoming more visible due to new requirements. The Patient Protection and Affordable Care Act, for instance, "designates PSOs to help hospitals with high readmission rates," and the Health Information Technology for Economic and
Clinical Health Act "encourages medical device users to report adverse events to a PSO," according to the report.
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Patient safety organizations were created to provide legal protection for healthcare professionals reporting adverse events. PSOs collect and analyze these reports and provide feedback to healthcare organizations on how to prevent adverse events in the future.
ECRI Institute PSO has been in existence for about four years. In a report called "Not Just Adverse Events: The Bigger Picture From Four Years as a PSO," ECRI Institute PSO leaders identify trends in adverse event reporting and management.
1. "RCA tunnel vision." Many organizations fail to review similar past events when conducting a root cause analysis, according to the report. In addition, many organizations do not share the results of root-cause analysis widely.
2. Patient safety culture. Patient safety culture remains crucial for sustaining patient safety improvements. A strong patient safety culture requires a combination of systems thinking and evaluation of human factors; a balance of low-, medium- and high-impact interventions; and support and communication from leaders, according to the report.
3. Slow adoption of PSOs. Some organizations are reluctant to join PSOs because they are not confident the legal protections will hold up in court, they believe PSOs are a fad or they are overwhelmed with quality reporting and related activities. However, a trial court in Kentucky upheld the legal protections in 2011 and PSOs can lessen the burden of reporting, according to the report.
4. PSO visibility. Despite some organizations' reluctance to participate in a PSO, PSOs are becoming more visible due to new requirements. The Patient Protection and Affordable Care Act, for instance, "designates PSOs to help hospitals with high readmission rates," and the Health Information Technology for Economic and
Clinical Health Act "encourages medical device users to report adverse events to a PSO," according to the report.
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