Posted in Alerts, EMS, EMS PSO Posted October 28, 2014
This Safety Watch is to advise you that having multiple different types of cricothyrotomy kits can lead to confusion during an airway emergency. We believe standardizing your equipment including cricothyrotomy kits within an organization or within a region would help to reduce the likelihood of an adverse event.
Cricothyrotomy also commonly called a “cric” is an emergent procedure for establishing an immediate airway. The procedure can be performed several ways with various commercially prepared kits or with specialty prepared equipment. The skill requires the provider to access the cricothyroid membrane to establish an airway for oxygenation and ventilation.
Possible reasons for these events:
- Access to different types of kits can lead to confusion during an airway emergency
View the full Safety Watch to see recommendations for mitigating risk.
Posted in Culture of Safety, EMS, EMS PSO, Events, Patient Safety Culture, PSES, PSO, PSO case law, PSWP, Sponsor/vendor Posted October 14, 2014
The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more! Download the newsletter or view on Issuu.
Posted in Alerts, PSO Posted October 7, 2014
The Center for Patient Safety has released a PSO alert regarding the potential for confusion when administering Midazolam or Morphine.
As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including EMS medication events.
Recently, there has been a trend of medication errors pertaining to the administration of the incorrect medication involving Morphine and Midazolam. Specifically, confusing the two medications and administering the wrong medication.
Possible reasons for the error:
- Similar names of medication
- Similar packaging or container
- Similar route of delivery
- Medications were locked together
- No cross check process in place or time out taken before administration
Read the full alert and view recommendations and helpful resources.
The Center is pleased to announce the date of our upcoming annual EMS Patient Safety Conference, scheduled for November 12, 2014. This conference is expected to be bigger and better than previous years, bringing national EMS experts together to share strategies to improve patient safety, highlight successful practices and provide broad networking opportunities to share successes and challenges. 7 CEUs available for attendees.
We invite you to register to attend or visit our conference page for more information!
Conference highlights include:
- David Williams, Institute for Healthcare Improvement Faculty will present Plan-Do-Study-Act
- Tom Judge, Executive Director at Lifeflight of Maine will present Safety Culture and Management of risk
- Michael Bachman from Wake County EMS in Raleigh, NC will present the Coordination of Patient Safety in Mobile Integrated Healthcare
- And much more!
Limited sponsor/vendor opportunities are still available – Sign up today!
The 2014 Medical Office User Comparative Database Report, released earlier this year, will be summarized by the Agency for Healthcare Research and Quality (AHRQ) via webinar on Tuesday, September 16, from 1-2pm EDT. Survey administration experiences and implemented improvement initiatives will be provided from the perspective of a system with more than 200 medical offices as well as a a federally qualified rural health center clinic. Register for this webinar.
The Center for Patient Safety (CPS) fully supports this diagnostic tool to measure your patient safety culture. If you are interested in administering the survey in your medical offices, let CPS provide you with an estimate., or learn more about CPS survey administration.
From the Center for Healthy Aging, National Council on Aging (NCOA):
Strong Today, Falls Free® Tomorrow
Date: September 23, 2014
The 7th annual Falls Prevention Awareness Day will be observed on September 23, 2014—the first day of fall. This year’s theme, Strong Today, Falls Free® Tomorrow, seeks to raise awareness about how to prevent fall-related injuries among older adults.
The Falls Free® Initiative is a national effort led by NCOA to address the growing public health issue of falls and fall-related injuries and deaths in older adults.
Posted in EMS, EMS PSO, Events, Patient Safety Posted August 11, 2014
Multiple stretcher-related incidents have been reported to the Center’s Patient Safety Organization. The areas of concern are from real events. Read the full Safety Watch on EMS Stretchers.