Over a two-year period, ECRI Institute PSO received reports of more than 1,300 events involving lapses in policies, procedures, or their execution. In the same time frame, 99 root-cause analyses (RCAs) were reviewed by ECRI Institute PSO; each RCA includes a section on the policies and procedures surrounding the event.

ECRI Institute PSO identified the following factors as contributory to the events presented in the RCAs:

  • Inadequate communication of standards, policies, and procedures
  • Policy/procedure enforcement is inadequate
  • Inadequate definition of responsibility for each item/activity in the policies or procedures
  • Lack of policies or procedures
  • Confusing, contradictory, or misleading policies or procedures
  • Incomplete policies or procedures
  • Recently changed policies or procedures

These factors were seen in the submitted events as well.