15 Years as a PSO. Decades Improving Safety.

This year, ECRI and the Institute for Safe Medication Practices PSO celebrates our 15th anniversary as an AHRQ-listed Patient Safety Organization. Over this decade and a half, we have worked tirelessly to build and maintain the trust and reputation that confirms ECRI and ISMP’s deep roots in safety . In our 15 years as a PSO, we have collected close to 6.5 million safety events, including over 4.4 million adverse events (events that reached the patient and caused a degree of harm), 880,000 near misses (an adverse event was averted), and 1.2 million reports of unsafe conditions (events that could have led to patient harm). Behind those numbers are the stories of people: moms and dads, sons and daughters, friends and neighbors, who have been unintentionally harmed in our health systems. However, there are also stories of brave healthcare team members who recognized the risk for harm and had the courage to speak up for safety, intervene, and catch that near miss before the patient was harmed. With our immense database of safety events comes a great responsibility to learn from these stories and understand the failures in our healthcare systems that lead to harm.  The learning and action that result from these events is how we will demonstrate our constancy of purpose for improving patient safety. 

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Topics: Patient Safety

The Insidious Dangers of Disposable Isolation Gowns—and How to Address Them

Posted by Karen Haberland, Senior Project Officer on Feb 6, 2024

Isolation gowns are a longstanding infection control tool across hospital settings. These garments are intended to safeguard patients and clinicians by preventing the spread of disease-causing microorganisms. But do today’s disposable gowns provide the degree of protection healthcare workers assume? Not necessarily.

ECRI believes there is a disparity between healthcare workers’ perceptions and actual gown performance. Consider, for example, this 2012 survey of infection preventionists. It found that about one-quarter of these professionals encountered strikethrough and 45% encountered tearing of gowns. What’s more, while a sizable portion had seen issues related to disposable gowns, half lacked the training to understand why. 

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Topics: Infection Prevention

Exploring Oral Hygiene’s Role in Reducing Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a lung infection that develops 48 hours or more after initiating invasive mechanical ventilation. Mechanical ventilation assists breathing in patients who have weak respiration and cannot independently breathe sufficiently to remain alive. Examples of invasive mechanical ventilation techniques include endotracheal intubation and tracheostomy. In endotracheal intubation, a physician places a long endotracheal tube in the patient's trachea (windpipe) through the mouth. In tracheostomy, the trachea is accessed through a small incision on the patient's neck. Tracheal secretion accumulation during intubation is a high risk factor for VAP, which can be caused by lung and lower respiratory tract colonization with microorganisms.

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Topics: Evidence-Based Medicine

Legal Perspective: Employee’s Alleged Use of Soiled Scissors Results in Real Harm

A home care client suffered infection and leg amputation after an employee allegedly trimmed dead skin off the client's foot with rusty scissors that had been used to cut off a soiled diaper. In a lawsuit brought against the agency and the employee, the Supreme Court of New York, Appellate Division, First Department, has affirmed denial of the agency's motion for summary judgment, allowing the suit to continue.

The employee used rusty scissors to cut the client's soiled diapers, then used the same scissors to cut dead skin off the client's foot, according to the allegations. The client suffered a foot wound, which became infected. Ultimately, the client required an above-the-knee amputation.

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Topics: Risk Management

Service and Support Animals: What Policy Is Right for Your Organization?

According to the Americans with Disabilities Act (ADA), individuals with disabilities must be allowed to be accompanied by their service animals in all areas of a place of public accommodation. ADA requires healthcare facilities, as places of public accommodation, to modify policies, practices, or procedures to permit the use of a service animal by an individual with a disability unless the presence of the animal would compromise health or safety standards, such as in the operating room.

A facility may ask an individual with a disability to remove a service animal from the premises only if any of the following conditions apply:

  • The animal is out of control and the animal's handler does not take effective action to control it.
  • The animal is not housebroken.
  • The animal is properly excluded.
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Topics: Risk Management

Could Natural Language Processing Help Close Gaps in Infection Prevention and Patient Safety Events?

Natural language processing (NLP) is an increasingly ubiquitous form of artificial intelligence (AI). Best described as where computer science meets linguistics, it uses computational linguistics and machine learning to analyze human language. 

NLP powers virtual assistants like Alexa and Siri, predictive text for emails, spelling and grammar checkers, and sentiment analysis in reviews. In addition to consumer use cases, NLP is used in medicine to identify risk factors, estimate risk, or predict events of disease development or readmissions across cardiovascular, endocrine, metabolic, and neurological diseases. And it’s put to work in patient engagement—with NLP-powered chatbots supporting pharmacy interactions, COVID-19 management, and primary care triage.

Does NLP have a potential role in supporting infection prevention? Let’s explore the possibilities.

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Topics: Infection Prevention

How To: Safe Administration of Vaccines

​​​​​​​Vaccinations are an important tool for building immunity to prevent illness, disability, and death resulting from infectious diseases. According to the Centers for Disease Control and Prevention (CDC), 4 million deaths worldwide are prevented by childhood vaccination each year.

As with any medication, errors can occur during the prescribing, preparation, handling, storage, or administration of vaccines. Vaccination errors can affect not only the patient receiving the vaccine but also others who are exposed to the patient if infectious diseases reemerge.

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Topics: Infection Prevention

Candida Auris Cases Are on the Rise. How Can Infection Prevention Respond?

Posted by Susan Singh, Infection Preventionist, ECRI on Oct 17, 2023

​​​​​​​Candida auris (C. auris)—an emerging fungus considered an urgent antimicrobial resistance (AR) threat—is on the rise in the United States. According to Centers for Disease Control and Prevention (CDC) data published in the Annals of Internal Medicine, C. auris spread at an alarming rate in U.S. healthcare facilities from 2020 to 2021. In fact, the number of cases resistant to echinocandins in 2021 was about three times that in each of the previous two years.

According to the CDC’s 2022 Special Report: COVID-19 U.S. Impact on AR, there were 171 clinical cases in 2017, 329 cases in 2018, and 466 cases in 2019. In 2020, there were 754 cases—representing a 60-percent increase. The CDC has categorized C. auris as an “urgent” pathogen based on the level of concern to human health. 

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Topics: Infection Prevention

Hand Hygiene: Fundamentals to Prevent HAIs

​​​​​​​Proper hand hygiene by healthcare workers is considered to be one of the most important practices for preventing healthcare-associated infections (HAIs) (CDC "Guideline for Hand Hygiene"). HAIs can happen anywhere healthcare is delivered including hospitals; outpatient settings such as doctor's offices, ambulatory surgical centers, and dialysis facilities; and long-term care facilities such as nursing homes and rehabilitation centers. They may be caused by any infectious agent, although most are caused by bacteria, viruses, or fungi (ODPHP).

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Topics: Infection Prevention

Building Effective Policies for Comorbidity Management

​​​Policies for managing comorbidities, as well as multimorbidity and multiple chronic conditions, vary based on the medical conditions involved; therefore, developing a uniform policy is not necessarily feasible given the differences between conditions. Approaches to comorbidity management often overlap with typical care management strategies. However, the presence of comorbidities often requires treatment adjustments based on disease-specific considerations, making individualized treatment plans the most appropriate approach. Professional organizations have developed guiding pri​​​nciples that healthcare organizations can use to tailor comorbidity management best practices. For example, see the following guiding principles for managing comorbidities developed by a working group convened by the American Geriatrics Society:

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Topics: Aging and Ambulatory Care

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