Patient Safety

New Tool In Development to Help EMS Spot Sepsis

    Posted in EMS, Patient Safety, Quality of Care    |    Comments Off

A team of physicians and other researchers at the University of Pittsburgh are hoping to be the winners of the 2014 Pitt Innovation Challenge award for their proposed “Sepsis Tool Innovator” to help EMS care providers and patients recognize the signs and symptoms of sepsis, bringing early intervention to patients even sooner.  For each hour of delay in the care of sepsis, the risk of death increases by 7%.  View the video and vote on your favorite innovation!

New Legislation Links LTC Medicare Reimbursement to Readmission

    Posted in LTC, Medicare Medicaid, Patient Safety    |    Comments Off

Congress has passed the “Protecting Access to Medicare Act of 2014,” which delayed the SGR rate reduction for physicians and directly links SNF and rehabilitation rates to hospital readmissions of Medicare patients.  The legislation had support from LeadingAge and the AHCA, as those organizations have looked for ways to reduce Medicare payments through improvements in care, not across-the-board cuts.  Information about the bill is available here.

CDC Reports

    Posted in HAI, Infection Prevention, Patient Safety    |    Comments Off

On March 26th the CDC released two reports that together show the progress that has been made to eliminate infections in hospital patients, and that more work on patient safety is needed.

The first report is a New England Journal of Medicine providing national healthcare associated infection estimates, stating that, on any given day, 1 of every 25 patients had 1 or more infections related to their hospital stay.  This equates to around 722,000 infections per year, and of those, 1 of every 9 patients will die from these infections during their hospital stay.

The second report is an annual report toward the U.S. Health and Human Services HAI prevention goals, which provided both state and national progress toward these goals.  Nationally, there has been a 44% decrease in central line-associated bloodstream infections from 2008-2012; a 20% decrease in surgical site infections (related to the 10 surgical procedures tracked) from 2008-2012; and a 3% increase in catheter-associated urinary tract infections.

For more infection and to access the reports, visit:

Center Releases 2013 Annual Report

    Posted in Center Info, Media, Patient Safety, PSO    |    Comments Off

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

CMS Will Look to LTC QAPI in Response to OIG Report of Adverse Events

    Posted in David Marx, Just Culture, LTC, OIG, Patient Safety, QAPI    |    Comments Off

One response to adverse events is the “crackdown” or, as David Marx from the Just Culture Community puts it, “getting whacked.”  The more productive response is to learn from the events and improve systems and staff performance.  In a call on March 13, CMS indicated that it plans to respond to the high number of LTC adverse events outlined in the recent OIG report by doubling down its support of QAPI.   This focus on improvement rather than punishment is reassuring and will lead to better care for LTC residents.  This is SUCH good news!  The call was reported by McKnight’s Long-Term Care News, and is available HERE.

CMS Issues Final Rule on ACA PSO Provision

    Posted in ACA, CMS, Patient Safety, PSO    |    Comments Off

CMS has issued the final rule (beginning on page 13814) pertaining to the ACA PSO provision requiring larger hospitals to participate with a PSO.  The final rule, as expected, delays the PSO participation requirement until at least 2017, instead allowing hospitals to meet safety assurances for participation in Quality Health Plans, that are part of Health Insurance Exchanges, by providing CMS Certification Numbers to the Plans.

OIG Report Highlights Adverse Events in LTC

    Posted in Events, LTC, OIG, Patient Safety, PSO, QAPI    |    Comments Off

The OIG report, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries[i]” has made quite a splash.  Of course, the Center for Patient Safety is excited that it recommends increased participation with Patient Safety Organizations.  But the report is a treasure trove of good information that can help to support safety efforts and QAPI program development.

The report found that 15% of Medicare SNF residents have preventable adverse events that cause greater than temporary harm.  In addition, 11% of residents had temporary harm.   The OIG used a trigger tool to help them identify medical records that reflected adverse events.  The report contains a good discussion of trigger tool methodology.

Administrators and directors of nursing should consider reading the report, which is less scary than it looks at first blush.  Here are some impressions:

  • There is one clear limitation to the report. First, the OIG only looked at Medicare residents in the first 30 days of their stay, and then only looked at the first 30 days of care.  This probably minimized the number of events they found.
  • On the other hand, it has some other powerful information, both in the data it contains and the light it sheds on HHS’ (and CMS’) thinking about adverse events, Patient Safety Organizations and QAPI.
    • The trigger tool itself and the description of its use can shed light on how to identify those unreported things in your home that surveyors will probably be looking for.  This supports QAPI’s requirement to identify areas for improvement.
    • The description of how the authors and their physician experts distinguished preventable and non-preventable events offers tremendous insight into how providers can evaluate and document the preventability their own events.  For example, the report did not consider pressure ulcers preventable if all recommended evidence-based care was delivered or attempted, AND the ulcer developed anyway due to co-morbidities that made evidence-based care difficult to provide or ineffective.
    • LTC providers need to improve identification and reporting of adverse events so that they can be studied and prevented.  The report recommends participation with Patient Safety Organizations to help accomplish that goal, and to allow for broader study and learning.
    • CMS needs to develop methods to encourage and the identification of events and the implementation of improvements.  Expect this to be a survey focus going forward.  The detailed information in the report about events it identified

The report is available at  The trigger tool is included as an appendix in the report.  More information about the Center for Patient Safety’s Long-Term Care PSO services can be found at


Welcome to Patient Safety Awareness Week, March 2-8!

    Posted in Patient Safety    |    Comments Off

Patient Safety Awareness Week is here!  The Center is pleased to host this week and provide Tips for Consumers about safe care and for Providers to share their successes.  Many Governor’s across the nation are acknowledging these efforts, including Gov. Jay Nixon in Missouri by signing a Proclamation!

And check out the Center’s Press Release about Safety Awareness Week!  Participate in our discussion on Twitter about how you are celebrating Patient Safety Awareness Week!

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