ECRI Blog

Avoiding the Blame Game in Preventing Medical Errors

In late 2017, a catastrophic medication error led to a patient death at Vanderbilt University Medical Center. While waiting for a PET scan, an elderly woman was incorrectly administered vecuronium, a paralyzing neuromuscular blocker, rather than the prescribed sedative Versed. It was reported that, because vecuronium suppresses normal respiration and the patient was left unattended while waiting for the test, she suffered cardiopulmonary arrest. Although she was resuscitated, it was too late to prevent brain death, and she was later removed from life support.

This case was widely reported in the media as an example of preventable medical errors that injure or kill too many patients, despite our efforts to make healthcare safer. As we reach the 20-year anniversary of To Err Is Human, the landmark Institute of Medicine report that crystalized the patient safety movement in the U.S., we must humble ourselves with the knowledge that while we’ve made many improvements, there is still much more work to do.

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Topics: Patient Safety

The Monopoly Board of Clinical Guidelines

Posted by Janice L Kaczmarek, Director, ECRI Guidelines Trust on Mar 11, 2019 9:29:06 AM

When the closure of the National Guideline Clearinghouse (NGC) hit the news, the ECRI team who worked on the contract felt as though we had lost a dear friend. After all, we had a 20-year history with NGC. That’s a long relationship by any measure. Yet, we had little time to mourn because we had an organizational commitment to disseminate evidence-based guidelines into practice.

ECRI’s decision to create its own guideline repository was welcome news to many members of the guideline community. However, it left some people wondering how our new repository would compare to NGC. I’m here to tell you that the ECRI Guidelines Trust™ is not a reboot of NGC. NGC was a groundbreaking initiative, and it should hold its own place in guideline history.

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Topics: Guidelines Trust

Your Smart Phone Will See You Now

The science of forecasting medical technology is lousy. We hear so many pundits predicting the next revolutionary medical technology advancement that it is literally impossible to keep track of them all.  It is not news that many of these predictions never come to pass. Nonetheless, amazing technology advances do occur and change medicine forever.

Just look back 80 years when hospital wards housed dozens of monstrous-looking devices called iron lungs. These life-saving devices treated people who were unable to breathe because of paralyzed chest muscles. Today, we don’t see hospitals with huge wards filled with iron lungs anymore. Who made that technology disappear? Certainly not the iron lung manufacturers. It wasn’t even a hardware technology innovation that changed patient care. It was a biologic—the polio vaccine—that changed the future of the hospital from treating dozens of polio cases to almost none. Who could have seen that coming?

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Topics: Industry Trends

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