Author Archives Alex Christgen, BSBA

AHRQ Releases WebM&M

    Posted in AHRQ, Patient Safety    |    Comments Off

The Agency for Healthcare Research and Quality has released the April WebM&M, morbidity & mortality rounds on the web.  Spotlighted case is “Dissecting the Presentation“, with additional cases: “Transition to Nowhere” and “Fire in the Hole! – An OR Fire“.

Surgical checklists are also addressed this month with an interview with Lucian Leape,MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, and an interview with David Urbach, MD, MSc, Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto.

Safety Alert Issued: High Alert Medications

    Posted in Alerts, PSO    |    Comments Off

PSOAlert!The Center for Patient Safety is issuing a Safety Alert based on industry data and recent findings from event data being submitted to the PSO.  The following areas of concern have been reported to the PSO:

  • A pediatric patient receives a higher than standard dose of Propofol and requires resuscitation.
  • A battery fails on an insulin IV pump and goes unnoticed.
  • Approximately one in every five reported PSO medication events involves a high alert medication such as anticoagulants (warfarin, heparin, Lovenox), Propofol, insulin, hypoglycemic agents, opioids and so forth. Events relate to prescribing, dispensing, administering and monitoring errors.

Read More…

Safety Watch Issued: Endotracheal Intubation in EMS

    Posted in Patient Safety, PSO    |    Comments Off

Safety WatchThe Center for Patient Safety is issuing a Safety Watch based on industry data and recent findings from event data being submitted to the PSO.  The following areas of concern have been reported to the PSO:

  • Tube dislodgement during patient movement
  • Patient aspiration
  • Rapid Sequence Intubation

Read More…

CPS Releases Annual PSO Report

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

The Center for Patient Safety has released the 2014 PSO Report, containing findings reported by healthcare providers.

The data contained in the report is from the Center for Patient Safety’s PSO database. Licensed healthcare providers may participate in a PSO in order to share information, learn from the sharing, gain federal protection to support open reporting and ultimately reduce mistakes and patient harm. PSO participation is voluntary and organizations may choose to submit most or all adverse events or they may choose to submit only the more severe adverse events to share lessons learned. The event types and their severities, along with additional information, contained in the report are deidentified as required by the PSQIA.

The goal of the report is to present an overview of the findings within all of the events reported to the Center’s PSO, to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.

General CPS findings include: Read More

CPS Safety Culture Survey – Look at the Subcultures

    Posted in Patient Safety    |    Comments Off

CPS focuses solely on patient safety, including Just Culture and CUSP training, and therefore, the survey is a clear connection between the services provided by the Center.  These programs positively impact the safety and the quality of healthcare organizations across the country and support a culture that encourages reporting of adverse events.

The Center has administered tens of thousands of culture surveys for hundreds of hospitals, medical offices, home care and nursing homes since 2010, utilizing the Survey on Patient Safety Culture (SOPS) measurement and diagnostic tool created by the Agency for Healthcare Research & Quality (AHRQ).

The greatest differentiator in the service offered by CPS is the comprehensive feedback reports at the unit level.  Each unit within an organization has a subculture (or co-culture) that exists, and while it still contributes to the overall culture, the subculture results can reveal unit-level concerns or best practices.

“We love the Center’s patient safety culture survey feedback reports. The department level reports give a level of granularity we were lacking with previous surveys.”

Find out more about CPS survey administration.

National CPS PSO Services

    Posted in Patient Safety    |    Comments Off

Patient Safety Organizations (PSOs) promote the reporting of adverse events, allowing healthcare organizations to reduce medical errors and patient harm; learn more about what errors occur, why they occur and how to prevent them; and network with others on sensitive patient safety topics. Healthcare organizations can submit event information to the PSO where patient safety experts analyze the events across hundreds of healthcare organizations across the country, monitoring trends, issuing alerts, and sharing ways to prevent future harm.

The Center for Patient Safety is one of the largest and most active PSOs in the country, working with hospitals, EMS services, medical offices and long-term care facilities.

Blue states indicate where CPS is providing Patient Safety Organization (PSO) Services:

CPS releases 2014 Annual Report

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2014 Annual ReportThe Center for Patient Safety (CPS) is pleased to share highlights of 2014 and expectations in 2015 in the latest annual report. We encourage you to take a look and see how you can join our journey to safer care in 2015!

Download PDF or View on Issuu

A Message from Becky Miller, Executive Director for the Center

    Posted in Becky Miller, Center Info, Patient Safety    |    Comments Off

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