One of the most important ways to prevent healthcare events from happening is to learn about problems that have occurred in other organizations and to use that information to prevent similar incidents elsewhere.
In response to adverse event reports received by ECRI Institute PSO and to promote such learning, ECRI Institute PSO has begun disseminating periodic Patient Safety E-lerts to participating organizations. The Patient Safety E-lert will bring attention to these issues and is concisely formatted to stimulate discussion and action by interdisciplinary committees focused on reducing the risk of healthcare events.
The first E-lert highlights a patient safety issue regarding retained guidewire fragments, a topic brought to ECRI Institute PSO's attention through reports submitted by participating healthcare providers. ECRI Institute PSO received four reported cases of retained guidewire fragments between December 2009 and March 2010. Despite the short reporting time period, ECRI Institute analysts recognized the value in learning from these events. The E-lert recommends that widely accepted patient safety techniques used in the operating room (OR), such as instrument inspection, should be utilized when interventional procedures are performed outside the OR. The full E-lert is being offered for free to the public in order to improve patient safety throughout the healthcare community.
ECRI Institute PSO, a component of ECRI Institute, has been officially listed by the U.S. Department of Health and Human Services as a federal PSO under the Patient Safety and Quality Improvement Act of 2005. ECRI Institute PSO directly serves as a PSO for providers. It also serves as the program of choice for numerous statewide PSO reporting programs.
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