Author Archives Alex Christgen

Center Releases 2013 Annual Report

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The Center for Patient Safety has recently released the 2013 Annual Report. In addition, the Center has provided a 2013 PSO Report that highlights and summarizes the data found in the Patient Safety Organization (PSO) database.

We hope you will see the value in the work that is being done by the Center in collaboration with many healthcare providers across the nation to improve the safety of healthcare delivery and the reduction of patient harm.

Click on a report to download:

2013 Annual Report   2013 PSO Report

Call for Poster Presentations at 8th Annual Conference

    Posted in Patient Safety    |    Comments Off

The Center for Patient Safety reminds you to submit a poster display of your great success in safe practices at our 2014 Patient Safety Conference, Friday, March 21 in St. Louis!

Join our popular conference poster session and share your successful safety practices.  Any healthcare professional or provider organization is invited to submit successful safety activities and projects for sharing.  This includes academia, pharmacists, nurses, physicians, hospitals, clinics, nursing homes, home health agencies, EMS agencies, ambulatory surgery centers and academia and others with learning to share.

Deadline to submit a poster has been extended to February 28, 2014.  Download the Poster Display Application.

Due to the popularity of the poster displays, space will be provided on a first-come, first-served basis.  Submit your poster display application today!

If you have questions or need assistance, please contact the Center or visit our conference website for further information.

March 2-8, 2014 is Patient Safety Awareness Week

    Posted in Patient Safety, Patient Safety Awareness Month, Patient Safety Conference, Toolkit    |    Comments Off

The Center for Patient Safety is joining Patient Safety Awareness Week this March to acknowledge:

“Safe Care is Our Focus, 24 hours a day, 7 days a week, 365 days a year”

In recognizing the year-round efforts to improve safe care, the Center is raising awareness by providing tools and resources for healthcare providers and consumers for Patient Safety Awareness Week!  This is how…..

  • Patient Safety Awareness Week Toolkit – a downloadable, customizable  resource for healthcare organizations to raise awareness about patient safety efforts – banners, posters, tent cards, buttons – and tips to help you get started!  VIEW and DOWNLOAD
  • Consumer Tips for Safe Care – highlighting consumer guidance and resources
  • Eighth Annual Patient Safety Conference, Safe Care: Our Focus 24/7/365, on March 21 in St. Louis. In-person and live streaming options available!  For more information or to register, visit

CPS Announces Eighth Annual Patient Safety Conference in 2014

    Posted in Center Info, Health Literacy Missouri, Patient Safety Conference    |    Comments Off

Center’s latest issue of PSONews is now available!

    Posted in Learning, Patient Safety, PSO, PSO case law    |    Comments Off




The Center’s Fall Edition of PSONews contains the following articles and more:

  • PSOs Collaborate…P1
  • PSO Protections…P2
  • Readmissions, Safety Culture…P3
  • Top Six Reasons to Participate…P4
  • National Webinar Series…P4
  • Center Tidbits…P5
  • Small Hospitals: Dilemma…P6
  • Tips for Successful Culture Survey…P7
  • EMS PSO Update…P7
  • PSO Data Snapshot…P8

Medical office toolkit from AHRQ to improve patient safety

    Posted in AHRQ, Ambulatory Care, Patient Safety, Physician Office, Toolkit    |    Comments Off

AHRQ’s recent bulletin highlights their new toolkit directed at medical offices to make the care delivery process safer:  “Improving Your Office Testing Process: Toolkit for Rapid-Cycle Patient Safety and Quality Improvement”

The toolkit includes materials for assessing office readiness, planning for improvements, assessing the testing process, patient engagement, patient handouts, and chart audit and EHR evaluation tools.  To find out more from AHRQ and download the toolkit, we encourage you to visit their website.

ALERT ISSUED: Preventing Retained Surgical Items

    Posted in Alerts, Preventable Errors, PSO    |    Comments Off

The Center for Patient Safety and The Joint Commission have released alerts regarding the preventing of retained surgical items.  The alerts reflect data the Center for Patient Safety (CPS) is seeing.

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 retained surgical items (RSI).  RSIs are unintentionally retained objects from an invasive procedure.

While RSI events do not occur often, they still happen.  In cases of RSIs, the item is often discovered and removed right away.  However, this requires additional surgical procedures, can cause the patient undue strain and may extend their recovery time.

PSO data reveals the most often reported retained items are sponges and guide wires, but other cases include broken surgical items like drill bits, and parts of instruments and devices.

Read More

Upcoming WIHI Broadcast: “Improving Safety and Satisfaction in Ambulatory Care”

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Next free WIHI broadcast from Institute for Healthcare Improvement (IHI) is Thursday, November 7, 2013, at 1PM CT:  Improving Safety and Satisfaction in Ambulatory Care.

“We don’t typically associate the ambulatory care setting with serious lapses in quality that threaten patient safety. Much of the improvement in recent years targeting outpatient care has focused on access, waiting times, communication, and coordination of care. But these areas ripe for change have often obscured others that, if not handled well, can have even more dire consequences: the ordering of tests, the timely handling and communication of results, and the overall process of making a diagnosis in response to a patient’s symptoms or complaints, including making referrals to specialists… On the program, we’re going to find out what’s been learned from a three-year initiative known as PROMISES, charged with reducing malpractice risk in the ambulatory setting by making care safer, more efficient, and more reliable.”

Speakers for this broadcast will include Gordon Schiff, MD, Associate Director, Brigham Center for Patient Safety Research and Practice, Brigham and Women’s Hospital; Nicholas Leydon, MPH, Director, PROMISES Project, Massachusetts Department of Public Health; Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI); Damian Folch, MD, Family Practice and Lifestyle Medicine (Chelmsford, MA).

Register for this broadcast.

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