Patient Safety

Medication Alert! Hospitals, ASCs and Anesthesia Professionals

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ISMP Medication Safety Alert for Hospitals, ASCs and anesthesia professionals! Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. ISMP is alerting hospitals, ambulatory surgical centers, and anesthesia professionals about the potential for dangerous mix-ups between two relatively new presentations of older medications, neostigmine injection and phenylephrine injection. Read more.

CPS Releases Annual PSO Report

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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

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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

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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 Recognizes Supporters at Annual Conference

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On March 13th, the Center recognized the following organizations and individuals for support since its inception in celebration of the Center’s 10th Anniversary:  Founding Members – Missouri Hospital Association, Missouri State Medical Association and Primaris; 10-year Board Members – Steve Bjelich, Dr. Edmond Cabbabe, Dr. Gordon Jones and Rick Royer; Long-term Platinum Sponsor – Healthcare Services Group and long-term Silver Sponsor – Missouri State Medical Foundation. Others recognized were Greensfelder, Hemker and Gale for their long-term sponsorship of the Center’s Conferences, Patient Safety Commissioners and other organizations and individuals that currently do or have sponsored the Center’s work.  We appreciate the support and commitment to safe care!

Notables from CPS March 13th Conference!

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Thanks to all Conference attendees, Speakers, Sponsors, Vendors and Poster Presenters contributing to a successful 9th Annual Conference Friday, March 13th!  A few notable thoughts from the Conference:  “Compassion heals the places you can’t touch”, Allison Massari; “The challenge continues to reduce harm, but we know we’re making a difference”, Christine Goeschel; “There is a lot more than can be done to share learning from serious events”, Patient Safety Commissioner Panel; “Diagnostic errors need to be identified and addressed”; Dr. Mark Graber.

A Message from Becky Miller, Executive Director for the Center

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FDA Issues Guidance on reprocessing ERCP Endoscopes, Best Practices for Practitioners and Patients

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Between January 2013 through December 2014 the FDA has received reports of MDRs encompassing approximately 135 patients in the United States relating to possible microbial transmission from reprocessed duodenoscopes. Likely many other incidents have occurred that were not reported to the FDA. Review this Alert for more information and best practices for practitioners and patients.

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