"If a system doesn't fully meet the (healthcare system's) needs, you don't want to leave an individual to come up with his or her own customized workarounds," she explains. "These are symptoms of suboptimal systems designs, and if you have a lot of them, you need to understand why staff adopt them and address their concerns."
The 36 hospitals that participated in the ECRI IT project are among the hospitals around the country for which ECRI serves as a Patient Safety Organization, or PSO.
PSOs are covered under a special federal law that allows hospitals to report incidents, near misses, and unsafe conditions immune from legal discovery and absent patient identification so those protections will encourage reporting of system and human mistakes without prompting blame, publicity, or litigation.
The 171 events documented, break down like this: