Patient Safety

Looking for a great gift idea that keeps giving?

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Your tax-deductable donation to the Center for Patient Safety supports ongoing patient safety education and resources to thousands of healthcare providers across the country. Make a donation and support safer care today!

The Center for Patient Safety values partnerships with organizations and individuals who want to support improvement in healthcare quality and patient safety. Because the Center is a not-for-profit organization, donations are tax-deductible.

There are three ways to join the effort to spread safety culture throughout the healthcare community: individual donation, organizational sponsorship levels, and/or supporters can sponsor an event or initiative.

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Insulin Pens: Are your patients safe?

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A success story from CoxHealth, Springfield, Missouri

Insulin pens were designed for convenience to permit a single person to administer multiple self-injections, using a new needle each time. Many hospitals began using the pens because of their convenience and accuracy. However, reports from several hospitals indicated that the pens were being reused, placing thousands of patients at risk. An alert from the Center for Disease Control in 2009 warned that the pens should be used on a single patient only and are not to be shared between patients. Despite this alert, inappropriate use in hospitals continues, indicating that some healthcare personnel do not adhere to safe practices and may be unaware of the risks to patients.
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About Patient Safety Organizations (PSOs): Did You Know?

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Now that Patient Safety Organizations (PSOs) have been in existence for more than five years, the federal Patient Safety and Quality Improvement Act (PSQIA) is better understood, and knowledge about the Act has increased. Still, there are a number of questions we commonly receive at the Center for Patient Safety.  Here are the top 10 questions, answered by the Center’s Patient Safety Specialist, Eunice Halverson at

Why should a health care provider join a PSO?
PSOs are independent, external experts who can collect, analyze and aggregate patient safety work product to develop insights into the underlying causes of patient safety events. Communications with PSOs are protected to allay fears of increased liability or fear of sanctions. With this federal protection, healthcare providers can share information with other participants, via the PSO, and learn from each other to ultimately improve patient care. More information is available from the AHRQ on working with a PSO.

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Taking the Bite Out of Flu for LTC

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Flu is upon us early, and even though the vaccine is not completely effective, fifty percent protection beats none. Not only can the flu vaccine protect residents, but it can also reduce the disruption from staff sick days.  Long Term Living magazine talks about how unfortunately, long-term care staff are far less likely to be vaccinated than staff in other healthcare situations.
The CDC has developed a toolkit specifically for LTC employers to help encourage the vaccination of their workforce.  It is available on the CDC website.

TeamSTEPPS Training Curriculum Now Available Online – Offered at no-cost!

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TeamSTEPPS Online Communication and Teamwork Course

AHRQ’s TeamSTEPPS® training curriculum is now available online as an accredited continuing education program, allowing health care providers to become certified as Master TeamSTEPPS Trainers through a web-based course.

TeamSTEPPS is an evidence-based teamwork approach to improve communication and teamwork skills among health care professionals. The TeamSTEPPS Online Master Trainer Course consists of 11 modules, 8 of which offer continuing education (CE) credits. Sample topics include Communication, Situation Monitoring and Mutual Support.

The training curriculum is engaging and includes videos, instructor guides, and slide presentations to further demonstrate the concepts presented in the course.

Learners in a cohort or noncohort group completing the full course of all 11 modules and a coaching session with a TeamSTEPPS Master Trainer not only receive CE credits but can also receive certification as a Master Trainer. Learners can also choose to complete individual modules for CE credits only.

Interested participants can begin the process by completing the TeamSTEPPS readiness assessment. The class is offered at no cost to participants on a first come, first serve basis. The course can be viewed at: .

November 20 is National Rural Health Day – Celebrate!

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The National Organization of State Offices of Rural Health and national and state partners are raising awareness of the Power of Rural on November 20th for National Rural Health Day.  Many resources include information about the care provided in rural communities including quality and safety of health care delivery.

Violent Resident Behaviors: Significant Safety Concern

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Resident-to-resident aggression is a significant issue for up to 20% of residents in skilled nursing units, according to a study from Cornell University, described in this article in Long Term Living magazine.  The Center for Patient Safety looks forward to working with long-term care providers through its PSO services to document and address these issues.  Want more information? 

AHRQ Issues 2014 Report on Nursing Home Safety Culture

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AHRQ has now collected data from thousands of nursing home safety culture surveys, representing 263 communities.  In October, AHRQ released a comprehensive report of that data.  It contains a number of interesting patterns based on the size, ownership (for profit or not-for-profit—the homes in the database are split about 50-50) and location (urban or rural) of respondents, and is available to anyone  on the AHRQ website. It also includes helpful material on how to analyze the results of your own survey and tools to use in developing action plans to improve safety culture.  Some highlights and lowlights:

  • Respondents consistently rated their homes well for providing safe care to residents and their willingness to tell someone if they see something that would harm a resident.
  • The scores also reflected a strong sense that there is good communication and feedback about incidents and how to respond to keep residents safe.
  • On the other hand, many respondents felt that their homes have a punitive response to errors, punishing the person rather than looking at the event.

The highest scores came from the Midwest, though those still left room for improvement.

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