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In its just released Patient Safety E-Lert, the ECRI Institute Patient Safety Organization (PSO) highlights a patient safety issue regarding radiation therapy to an unintended site, an issue brought to ECRI Institute PSO’s attention through reports submitted by participating healthcare providers. As part of ECRI Institute’s mission to research the best approaches to improving patient care, this information is being provided to the healthcare community as a free download.

ECRI Institute PSO received two reports submitted between September and November 2009 involving delivery of radiation therapy to unintended body regions. Additionally, ECRI Institute has investigated many radiation safety problems over several decades. In so doing, the nonprofit organization has gained substantial expertise in determining the causes of errors involving unintended radiation. The full E-lert, being offered for free download, includes key contributing factors and recommendations for improving patient safety from unintended site radiation. This topic is also covered in “Top 10 Health Technology Hazards for 2011,” published in the November edition of ECRI Institute's Health Devices journal.

“One of the most important ways to prevent healthcare events from happening is to learn about problems that have occurred in other organizations and to use that information to prevent similar incidents elsewhere,” said Karen P. Zimmer, MD, MPH, FAAP, Clinical Director, ECRI Institute PSO. “The Patient Safety E-lerts bring attention to these issues and are concisely formatted to stimulate discussion and action by interdisciplinary committees focused on reducing the risk of healthcare events.”

ECRI Institute PSO, a component of ECRI Institute, 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 providers.  It also serves as the program of choice for numerous statewide PSO reporting programs.

Source: ECRI Institute