ECRI Data

Bob Latino blatino at RELIABILITY.COM
Thu Nov 8 18:45:54 UTC 2018


‘RCA’ is an ill-defined term (https://www.linkedin.com/pulse/stigma-rca-whats-name-bob-latino/) but it is a Joint Commission requirement and had been since about 2000.

It is my understanding that ECRI is also a Patient Safety Organizations (PSO) and provides essentially a safe haven for RCA’s to be submitted and protected from discovery.  ECRI’s PSO reviews, analyzes and provides feedback to RCA submitters on the quality of their RCA’s and how to improve upon them.  In this role they become a warehouse for these RCA’s and try to make sense of the commonalities they find across the country via analytics.

‘RCA’ is the more familiar term in healthcare, whereas ‘Failure Analysis (FA)’ is more widely known in the manufacturing sectors. FA is often associated only with component type failures or the physics of failure.  It is not more widely known for applying to non-component failures (i.e. – safety injuries not involving equipment) nor with delving into decision-making and organizational system deficiencies (i.e. – the ‘soft’ or human issues).

The term RCA, has the ability to be interpreted more broadly and thus distancing itself from just being viewed as applicable to components.  However, because of a lack of a universally accepted definition of ‘RCA’, it is often left up to the entity to define how they apply it.

Bob

Robert (Bob) J. Latino
CEO
Reliability Center, Inc.
804-458-0645 (Work)
804-452-2119 (Fax)
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
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Connect on LinkedIn<http://www.linkedin.com/in/robert-bob-latino-3411097>

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From: Sherrill Franklin [mailto:sfranklin131 at GMAIL.COM]
Sent: Thursday, November 08, 2018 12:31 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] ECRI Data

Do any of you know if “Root Cause Analysis” and/or  “Failure Analysis” are routinely employed in any health care setting to reduce errors?

If this process has been used, what have been the obstacles, pitfalls, successes?

Thanks,
Sherrill


Sherrill Franklin







On Nov 8, 2018, at 12:05 PM, Lorie Slass <Lorie.Slass at IMPROVEDIAGNOSIS.ORG<mailto:Lorie.Slass at IMPROVEDIAGNOSIS.ORG>> wrote:

Here is the ECRI report - https://www.ecri.org/EmailResources/PSRQ/Top10/2018_PSTop10_ExecutiveBrief.pdf




Lorie Slass
Vice President of Communications and Marketing
Society to Improve Diagnosis in Medicine (SIDM)
Lorie.Slass at ImproveDiagnosis.org<mailto:Lorie.Slass at ImproveDiagnosis.org>
Phone: 215.801.4057
www.improvediagnosis.org<http://www.improvediagnosis.org/>
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From: Janet Gilbreath <0000001584f7bb70-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000001584f7bb70-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Thursday, November 8, 2018 11:52 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] ECRI Data

I would love to see the top 10 patient safety concerns for 2018.  Would you mind putting me in touch with the person who presented this?

Thanks so much,
Janet Gilbreath
Walmart Care Clinics

On Thursday, November 8, 2018, 10:40:23 AM CST, Lyn Behnke <lynbehnke at GMAIL.COM<mailto:lynbehnke at GMAIL.COM>> wrote:


Bob, that would be amazing if I could have access.  I am really interested in diagnostic error related to EHR..


> On Nov 6, 2018, at 12:45, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:
>
> I spoke at the National Association of Healthcare Quality (NAHQ) this week, and listened to a presentation by a colleague of mine from ECRI. It was entitled ‘The Top 10 Patient Safety Concerns for 2018’.  For the first time Dx Error not only made the list, but topped it.
>
> I spoke with my friend about their event /incident database which houses over 6 million incidents collected via their PSO nationally.  This DB is the basis for determining such Top 10 lists.
>
> I asked her if SIDM could have access to this knowledge base for research purposes and she said they do have such accommodations.  I also asked if this list could be data mined to cull out only bad outcomes resulting from Dx Error and she said yes.
>
> This would be a means of quickly identifying which bad outcomes to focus on per Rob Bells suggestion.
>
> This is just an FYI as this is a pretty substantial database that is maintained very well to keep up the integrity of the data.
>
> If this is worth checking out, let me know and I will connect you with my contact at ECRI.
>
> Bob Latino
>
> Sent from my iPhone
>
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