Case Studies
Protecting Patients Strengthens the Bottom Line
As healthcare organizations face growing financial pressures, many leaders are examining how safety and quality initiatives contribute to long-term organizational stability. Increasingly, boards and executives are recognizing that investing in patient safety is not only a clinical imperative but also a sound business decision.
Evidence shows that preventing harm reduces direct and indirect costs—lowering claims, readmissions, and length of stay, while improving staff engagement and operational reliability. ECRI’s experts in patient safety, systems design, and human factors engineering have seen these benefits firsthand through partnerships with hospitals, health systems, and senior care services organizations across the country.
The following examples illustrate how strategic investments in safety lead to measurable improvements in outcomes, efficiency, and financial performance.
Reduced Patient Falls across 10+ Senior Care Facilities
ECRI helped a network of senior care facilities reduce patient falls by 11% and saved them up to $2.7 million in falls-related claims and litigation in just the first 18 months of the initiative.
Falls are a leading cause of injury and death among older adults, with more than 36 million falls and 32,000 deaths reported annually in the U.S.¹ Each incident can cost up to $239,000² in medical expenses, claims, and litigation, as well as harm to patients.
11%
FEWER PATIENT FALLS
$2.7M
COST AVOIDANCE
12 Facilities
SYSTEM-WIDE IMPACT
One of ECRI’s senior care clients identified a troubling rise in falls across 12 member facilities, averaging nearly 200 falls per campus annually.
ECRI developed a 3-year collaborative designed to help strengthen falls management programs and build Quality Assurance and Performance Improvement (QAPI) capabilities. Through consulting, roundtables, and targeted training, the initiative helped identify performance improvement opportunities, drive purposeful change, and monitor results. It created a mechanism to report and analyze data, build performance improvement projects (PIPs) specific to each facility’s circumstances contributing to falls, and ensure implementation and accountability. As a result, the facilities significantly reduced fall rates, improved resident safety, and achieved substantial cost savings in under two years.
Decreased Sepsis Mortality with Human Factors Redesign
After ECRI helped a multi-state health system revolutionize its sepsis management system, an estimated 700 lives were saved plus approximately $30 million in cost savings from reduced hospital stays, improved treatment protocols, and improved efficiencies.*
Sepsis is a life-threatening condition requiring fast, accurate diagnosis and treatment. When a multi-state non-profit health system's Severe Sepsis/Septic Shock Mortality Index rose to 1.47, leaders introduced a Sepsis Navigator (SN) tool in the EHR to speed up detection. But poor usability, high false alarm rates, and workflow disruptions caused alert fatigue and frustrated clinicians. Nurses often bypassed the tool, limiting its effectiveness.
~700
LIVES SAVED
$30M
COST SAVINGS
25%
REDUCED MORTALITY
The health system turned to ECRI for help. They expected ECRI's Human Factors Engineering (HFE) team to assess the tool itself, but the team took a broader systems view—analyzing technology, workflows, workarounds, workspaces, and organizational policies.
Through interviews, focus groups, and observation, ECRI identified key issues and recommended improvements, including increasing the specificity of the alerts to reduce false alarm rate, showing clinicians the data behind alerts, involving staff in the redesign, and modifying the directives in the sepsis alert messages.
The redesigned SN tool and updated workflow reduced false alarms, improved usability, and boosted clinician trust and engagement. The health system quickly achieved a 25% reduction in sepsis mortality and significant cost savings.
* Based on this health system's data aggregation and analysis platform that pulls info from their EHR and other sources.
Reducing Heparin Errors Cuts Avoidable Hospital Costs
ECRI helped a health system with their goal of reducing heparin administration errors—addressing a problem that contributes to an estimated $2.5 billion in excess U.S. hospital expenses each year.
A multi-state non-profit health system identified a pattern of recurring errors in the administration of heparin, a high-risk anticoagulant, across multiple hospitals. Heparin errors pose significant safety risks, including the potential for under- or overdosing, which can lead to serious patient harm. They are among the preventable adverse drug events (ADE) from injectable medications that cost the U.S. healthcare system an estimated $2.7 to $5.1 billion annually.³ It is estimated that heparin-related adverse drug events specifically increase hospitalization costs by 4.5%, which translates to an additional $2.5 billion (approximate) each year in hospital expenses.
This ECRI client was experiencing several challenges, including failure to adjust heparin drip rates per protocol, incorrect values or weight entries in infusion pumps, data entered into the wrong fields on pumps, delayed PTT draws, and boluses not administered or documented properly.
ECRI’s HFE team conducted site visits, interviews, and workflow analyses to uncover the root causes of the six types of frequent errors.
The health system is now implementing targeted system-level improvements recommended by ECRI, including redesigned EMR order displays, simplified nurse-driven heparin protocols, standardized checklists for independent double-checks, and EMR nudges to prompt timely lab draws. These changes aim to reduce high-cost ADEs, improve medication safety, and standardize care delivery across all hospitals.
Improved Sterile Processing Can Save Up to $9 Million Annually in OR Time
ECRI helps identify and address sterile processing issues that cause instrument contamination and surgical delays – which are estimated to result in up to $9 million in recovered chargeable OR time a year.
Errors in sterile equipment processing can cause patient harm, clinical and operational disruptions, and financial and legal consequences. ECRI has helped healthcare organizations experiencing repeated surgical delays due to instrument contamination, missing trays, and reprocessing failures address systemic issues.
$153
COST PER OR MINUTE
10+ MIN
AVG SURGICAL DELAY
$6-9M
ANNUAL LOSS RECOVERED
A recent analysis at a major academic healthcare campus revealed that each minute of lost OR time cost $153,⁴ and the average delay per surgical case exceeded 10 minutes. The estimated cost of lost chargeable OR time for all inpatient and outpatient cases for the system was between $6 and $9 million⁴ a year—not including the additional costs related to reprocessing trays or replacing lost instruments.
ECRI’s vendor-neutral experts conduct multidisciplinary assessments to identify systemic failures, including water and steam quality issues, communication gaps between the Sterile Processing Department and OR, frequent equipment malfunctions and inadequate maintenance, and inconsistent adherence to evidence-based practices.
ECRI is helping healthcare organizations recover millions in lost surgical revenue. In one recent example, an acute care hospital called on ECRI to redesign its infection prevention processes, improve cross-departmental communication, and align operations with regulatory standards to avoid costly surgical delays and patient harm.
CAUTI Prevention Avoids Significant Costs
ECRI helped a health system reduce catheter-associated urinary tract infections (CAUTIs) and avoid hundreds of thousands of dollars in potential costs.
A Midwest health system identified a troubling increase in CAUTIs, resulting in both patient harm and significant financial risk. Each CAUTI was estimated to cost $22,568, translating to a potential $541,000 annual burden if that trend continued. Internal reviews revealed inconsistent practices across departments in perineal care, indwelling urinary catheter care, and site preparation for catheter insertion.
50%
REDUCED CATHETER UTILIZATION
97%
COMPLIANCE
$22,568
COST PER CAUTI AVOIDED
Partnering with ECRI and the ISMP PSO, the health system implemented a comprehensive, multidisciplinary prevention strategy. The initiative included reviewing catheter indications with hospitalists and ED providers to reduce unnecessary utilization, increasing visibility of CAUTI prevention reports, and reshaping behaviors by recognizing and rewarding high performers.
The program cut indwelling urinary catheter utilization by 50% within five months and achieved sustained 97% compliance with indwelling urinary catheter care across nursing departments and 98% compliance in the ICU—improving patient outcomes while delivering substantial cost avoidance.
The Takeaway: Safety Is the Smartest Investment
These case studies demonstrate that improving patient safety isn’t just the right thing to do, it’s one of the most effective strategies for strengthening organizational performance. Every initiative, from reducing falls and infections to preventing medication errors and surgical delays, shows how ECRI’s expertise translates into measurable outcomes: fewer adverse events, healthier patients, and millions saved in preventable costs.
By combining evidence-based safety science, system design, and human factors engineering, ECRI helps healthcare organizations transform safety from a regulatory obligation into a strategic advantage—one that protects patients, empowers staff, and drives sustainable financial results.
References
Older adult falls data. Centers for Disease Control and Prevention. October 28, 2024. Accessed November 13, 2025. Older Adult Falls Data .
Freeman G. Financial effect of fall prevention can be significant. Healthcare Risk Management. August 1, 2022.
Lahue BJ, Pyenson B, Iwasaki K, Blumen HE, Forray S, Rothschild JM. National burden of preventable adverse drug events associated with inpatient injectable medications: healthcare and medical professional liability costs. Am Health Drug Benefits. 2012;5(7):1-10.
Nichol PF, Saari MJ, Navas N, et al. Observed rates of surgical instrument errors point to visualization tasks as being a critically vulnerable point in sterile processing and a significant cause of lost chargeable OR minutes. BMC Surg. 2024;24(1):110. Published 2024 Apr 15. doi:10.1186/s12893-024-02407-1
More Ways We Help
Patient Safety Organization
Build a culture of safety with patient safety expertise, guidance, data, and broad subject matter knowledge.
Learn More