Patient Safety

ISMP LTC AdviseERR Addresses Distractions and Interruptions

    Posted in LTC, Patient Safety    |    Comments Off

CPS has given the ISMP’s LTC AdviseERR shout outs in the past.  We also talk a lot about distractions and interruptions as one of the most widespread causes of mistakes.  ISMP takes on the distraction issue in its latest issue of its long-term care medication safety newsletter, available here.  This issue speaks to the scope of the problem and has some great suggestions for controlling it.  Subscribe to the newsletter.

2015 Changes in Nursing Home Oversight and Consumer Reporting

    Posted in CMS, Patient Safety    |    Comments Off

Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five-Star Quality Rating System:

• Beginning in January, focused survey inspections for a sample of nursing homes improve verification of staffing and quality measure information that is part of the Five-Star Quality Rating System.

• Implementing a quarterly electronic reporting system to audit payrolls to verify staffing information to improve accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and staffing levels.

• Increasing the number and type of quality measures used in the Five-Star Quality Rating System.

• Strengthening requirements for states to maintain user-friendly websites and complete inspections of nursing homes in a timely and accurate manner.

• Improving the scoring methodology for calculation of facility quality measure ratings that are used for the Five-Star rating.

TeamSTEPPS Training Courses Posted, TeamSTEPPS in Primary Care

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The Center gets many questions about TeamSTEPPS training.  Nationally, Master Training Course information for 2015 is now available!  Registration for TeamSTEPPS Master Training Course for Primary Care, adapting the core concepts of TeamSTEPPS for primary care office-based teams, is available at  Additionally, general Master Training Course registration for classes January through May is expected to be available in early November at

October is “Talk About Your Medicines” Month

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October 2014 is recognized as “Talk About Your Medicines” month by the NCPIE in participation with the American Pharmacists Association Foundation. October brings awareness for patients and caregivers about benefits of documenting medications, sharing that with families and health care providers and talking with pharmacists to coordinate medication refills and compliance.

Two Studies: Medication Errors Reduced by IT Use

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A recent study in Florida on electronic medical record use, published in The Journal of Delivery Science and Innovation, reveals the adoption of core meaningful use medication management elements correlate with reductions in Adverse Drug Events. Another study by the AHRQ reveals the use of alerts for CPOE prescribed medications prompting prescribers to lack of corresponding indications for the medication identifies drug name confusion and prevents errors.

Resources to Improve Surgical Care, Reduce Infections and Wrong-Site Surgery

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The latest issue of AHRQ’s Health Care Innovations Exchange includes features QualityTools including resources and checklists to help hospitals deliver safer surgical care by reducing surgical infections, complications and related deaths and preventing wrong-site surgeries in addition to case studies and other interesting information on improving surgical safety.

Ask the Lawyer: PSOs & the Law

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PSO and the Laq

The Center for Patient Safety would like to thank the many who joined us for the EMS PSO Webinar on October 1, “Ask the Lawyer: PSOs and the Law”.  The webinar drew a very wide group of EMS and other healthcare professionals from around the country.  Kathy Wire, JD, MBA, CPHRM, led the presentation then opened up the remainder of the program to questions.  Kathy outlined the 2005 Patient Safety Quality Improvement Act and how participation would provide federal protection around much of the quality and safety efforts that EMS was already doing.  Kathy said “EMS is great to work with; they have a keen interest in quality and safety”.  The webinar focused on what a PSO is and how it supports the needs of quality and safety work.

Watch the recording

Lee Varner, BS, EMS, EMT-P, EMS Project Manager at the Center for Patient Safety, was impressed with the diversity of those who participated with the webinar.  Lee said “the topic attracted both ground and air EMS as well as many leaders in our industry”.  The goal of the webinar was to help raise awareness to the importance of reporting unsafe conditions, near misses, and adverse events.  Participating with a PSO and sharing information in a safe way allows EMS to learn one another and drive best practices in our industry.

Read more about the Center for Patient Safety’s EMS PSO.

New issue of WebM&M available

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The Agency for Healthcare Research and Quality (AHRQ) has released their latest issue of  WebM&M (“morbidity & mortality rounds on the web”).  AHRQ case topics include:

A Lot of Pain (Medications) - Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called.  Read the full case and commentary

Too Much, Too Fast – A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful. Read the full case and commentary

No BP During NIBP – A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned. Read the full case and commentary

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