Patient Safety

PSOs Are Watching New Florida Decison about PSWP

    Posted in Patient Safety, Patient Safety Act, PSES, PSO, PSO case law, PSWP    |    Comments Off

A Florida trial court order regarding the discovery of hospital incident reports is circulating in PSO circles.  (Charles v. Southern Baptist Hosp. et al., Duyal County, Case No. 15-2012-CA-002677.)  The order expresses a very restrictive view of PSWP (more below) and the hospital has expressed an intention to appeal the order.  As a trial court order in Florida, it has no value as precedent in any other jurisdiction, even within Florida.  However, the order will be part of the ongoing discussion about PSO protections, so CPS wants its stakeholders to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.  The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP. Read More

CPS issues Safety Watch on EMS Stretchers

    Posted in EMS, EMS PSO, Events, Patient Safety    |    Comments Off

Safety WatchMultiple stretcher-related incidents have been reported to the Center’s Patient Safety Organization.  The areas of concern are from real events.  Read the full Safety Watch on EMS Stretchers.

Released 08.11.2014.

EMS Hand Washing Study

    Posted in Patient Safety    |    Comments Off

EMT Hand-Washing Habits Need Improvement
Have you read this interesting and surprising study about EMS and hand sanitizing?  As an industry we might want to study and discuss it further as well as support each other for better compliance?  Does it raise a deeper question?  What about the equipment we touch while taking care of our patients?  When we are gloved are we risking cross contamination to ourselves and our next patient? Furthermore, think about the cab of our ambulances with the many things we touch and have contact with.  Is there any risk there?  Most services are vigilante and proactive with their disinfection process, however, we are prone to slips and drift from best practices.

What are your thoughts, do you wash your hands?

New ISMP Long-Term Care AdvisERR newsletter

    Posted in Patient Safety    |    Comments Off

The Institute for Safe Medication Practices (ISMP) has issued the July edition of its newsletter, Long-Term Care AdvisERR.  The newsletter includes tips on safe administration of U-500 Insulin, safe use of new oral dispensers for morphine sulfate, as well as addressing how to set up your MAR to avoid confusion.  Here is a link to subscribe to this free resource that offers advice on frequently reported medication safety events and access past issues.

AHRQ and The Joint Commission e-learning module for LTC

    Posted in Patient Safety    |    Comments Off

The Agency for Healthcare Research and Quality (AHRQ) and The Joint Commission released an e-learning module last week aimed at reducing healthcare-associated infections (HAIs) in assisted living and nursing homes.  The tool is available to all long-term care facilities and includes resources and quizzes in an online format.   The objective of the tool is to provide principles to “prevent infections and achieve high safety performance over extended periods of time”.

Opportunity for Long Term Care Facilities!

    Posted in LTC, Patient Safety    |    Comments Off

National Collaborative to Reduce Infections, Focus on CAUTI!  SIGN UP BY AUGUST 29th!

The Center for Patient Safety and Missouri Hospital Association are partnering to bring national faculty and resources to Missouri nursing homes to work collaboratively on reducing infections with a focus on eliminating CAUTI!  Sign-up for this opportunity is only available until August 29th!  There is no cost for participating in this collaborative!

To learn more about the project:

Register to participate on the national informational call on August 5th at 2 PM CST. Register for the call here!

For additional information, including an overview of the project, team leaders responsibilities and a downloadable Project Interest Form, go here.

If you have any questions, please contact Kathy Wire at the Center for Patient Safety at or Jessica Rowden at the Missouri Hospital Association at

Did you miss the NHTSA EMS Focus Webinar?

    Posted in Patient Safety    |    Comments Off

Last month, NHTSA’s Office of Emergency Medical Services (OEMS) hosted the first installment of its EMS Focus: A Collaborative Federal Webinar Series.

The first webinar, moderated by Dr. Brinsfield, Federal Involvement in EMS — provided the EMS community with an opportunity to discuss EMS activity at the federal level – in real time. The priorities include:

  • Evidence Based Guidelines
  • Preparedness
  • Military to Civilian Credentialing

For this recording or future webinars visit their website.

PSOs connect to share legal overview with participants

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

On July 17, 2014, PSO Participants were invited to attend “PSO Participation and Protections – a Practical and Legal Perspective”, a webinar cohosted by the North Carolina Quality Center PSO and the Center for Patient Safety PSO.  Topic coverage included legal perspectives and PSOs presented by Michael R. Callahan. Mr. Callahan also reviewed case law and the North Carolina, Illinois and Missouri Statutes.  CPS PSO Participants can download materials and watch the recorded session.

Switch to our mobile site