New Patient Safety E-lert, available now for free, addresses reported problems with cardiac monitoring of incorrect patients
PLYMOUTH MEETING, Pa., May 23, 2011 /PRNewswire-USNewswire/ -- In a recently released Patient Safety E-lert, the ECRI Institute Patient Safety Organization (PSO) highlights a patient safety issue involving cardiac monitoring of incorrect patients. The issue was brought to ECRI Institute PSO's attention in its analysis of reports submitted by participating healthcare providers. As part of its mission to research the best approaches to improving patient care, ECRI Institute is sharing this special E-lert with the healthcare community.
ECRI Institute PSO reviewed numerous reports of cardiac monitoring of the wrong patients resulting in the deaths of unmonitored patients who experienced critical arrhythmias.
"Ensuring positive identification of patients is a challenge in all healthcare settings," says Karen Zimmer, M.D., Clinical Director, ECRI Institute PSO. "Reports submitted to Patient Safety Organizations can help raise awareness of undetected risks occurring in hospitals and healthcare systems," Dr. Zimmer adds.
According to the E-lert, the potential for identification errors is significant in acute care settings, where a wide range of interventions are delivered in multiple locations by numerous staff who work in shifts. The extent of harm to patients caused by misidentification is unknown.
"Although this is being seen in a cardiac monitoring situation, this caution applies to more situations throughout the healthcare system. This advice should be applied to all systems where it has potential to occur," advises Barbara Rebold, RN, MS, CPHQ, Director of Operations, ECRI Institute PSO.
ECRI Institute's patient safety analysts caution that patient misidentification can be a causative factor in adverse events involving medical services; invasive procedures; blood transfusions; medication, laboratory, or pathology specimen preparation; and monitoring. The full E-lert, available as a download in our new library of free PSO resources, includes key contributing factors and recommendations to help healthcare facilities address these risks.
ECRI Institute PSO, a component of ECRI Institute, is leading Patient Safety Organizations in sharing lessons learned and providing aggregated data reports to help member organizations find the best approaches to patient safety. ECRI Institute PSO 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 hospitals and other healthcare providers. It also provides technical and analytic support for numerous statewide PSO reporting programs.
For more information about ECRI Institute PSO, or to request assistance with patient identification accidents or near misses, visit www.ecri.org/pso; contact firstname.lastname@example.org; call (610) 825-6000, ext. 5558; or by mail at ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.
For 43 years, ECRI Institute's work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. The ECRI Institute PSO—Patient Safety Organization—is a component of ECRI Institute, a nonprofit 501(c)h(3) organization dedicated to improving the safety, quality and cost-effectiveness of patient care. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality and a Collaborating Center for Patient Safety, Risk Management and Healthcare Technology by the World Health Organization. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other health care facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit https://www.ecri.org. Find ECRI Institute on Facebook (www.facebook.com/ECRIInstitute) and Twitter (www.twitter.com/ECRI_Institute).
SOURCE ECRI Institute