ECRI Blog

The ECRI and ISMP Patient Safety Organization has reached a milestone: more than 5 million events reported since its inception. However, two thirds of the reports were about actual events that reached the patient. Only 15% were labeled as “near miss” events, incidences that were "close calls." This is despite the well-known fact that near miss events are 10 to 100 times more common than actual events. Why is that?

Patient safety experts have long emphasized the necessity of creating a culture in which healthcare providers can freely report errors or other potentially avoidable events. This information can be protected by submitting the report, and all the investigations associated with it, to a patient safety organization (PSO). An exception exists only for events that must be reported to the state or an accreditation agency, but even there, any investigations and deliberations are protected when reported to a PSO under the Patient Safety and Quality Improvement Act of 2005.

Achieving the status “High Reliability Organization (HRO)” is now the gold standard for healthcare organizations, but there is little agreement on how to achieve it. To help you move your organization toward this important goal, let’s try to make that term clearer. Authors Weick and Sutcliffe first used the phrase in their 2001 book, Managing the Unexpected, now in its 3^rd revision (Weick, K. E., & Sutcliffe, K. M., 2015 Managing the unexpected, John Wiley & Sons).

Healthcare workers want to keep patients safe and provide high quality care. Unfortunately, despite best intentions, erroneous, substandard, and unequal care are still too common, harming 1 in 10 hospitalized patients in the US. Today’s evidence-based Patient Safety Organizations (PSOs) are working toward zero-avoidable-harm healthcare. Choosing the right PSO can help your organization reach this goal.

The World Health Organization defines Patient Safety as: “A framework of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur.”