The Joint Commission released Sentinel Event Alert #57

The Joint Commission released Sentinel Event Alert #57 this week:  The Essential Role of Leadership in Establishing a Patient Safety Culture.

The Center for Patient Safety supports the 11 patient safety tenets and provides services and supports to help health care providers across the continuum improve patient safety.  For additional information contact us.

It’s Patient Safety Awareness Week – #PSAW2017

The Center for Patient Safety encourages providers to use the week as a great way to remind the staff and community of their commitment to safety.
It should be a time of celebration of successes, but also a time of reflection.

In recognition of the week, and the efforts that continue every day throughout the year, the Center for Patient Safety is offering a 20% discount on the already affordable safety culture survey services. Download a proposal with sample feedback reports and an online sample survey link. We encourage the use of the survey as a diagnostic tool to assess your culture. Get started today and take advantage of the offering!

Several available toolkits can support your improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also want to remind you that consumer involvement is important to ensure a successful patient safety program. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement your events and programs during Patient Safety Awareness Week:

Patient Safety Awareness Week Approaches, March 12-18th

The Center for Patient Safety (CPS) encourages all healthcare organizations to use Patient Safety Awareness Week, March 12-18th, as a way to remind staff and community of your commitment to safety. It should be a time of celebration of successes, but also a time of reflection.

Free Toolkit for Patient Safety Awareness Week 2017

CPS reminds you to plan in advance for Patient Safety Awareness Week. Plans don’t have to be time consuming or extravagant, but a little planning can go a long way. We recommend hosting an event or several events to recognize patient safety efforts at your organization.

For example:

  • Recognize staff and committees that work every day to provide safe care
  • Launch a patient safety culture assessment during the week (mention this blog and receive 10% off your survey services through CPS!)
  • Have leadership, patient safety/risk/quality department and/or safety committees host events in the cafeteria with snacks or dessert or something special to celebrate safety at their organization
  • Ask departments to develop poster presentations of their successful safety efforts. Display in hallways.
  • Hang a safety awareness week poster in the foyer of the organization with signatures from all staff
  • Hold safety-focused training during Patient Safety Awareness Week
  • Publish safety-focused articles for the organization’s internal newsletter, professional newsletters, local newspapers, local consumer groups
  • Contact a local radio station to host a spokesperson to share patient safety tips and highlights
  • Launch a new safety awareness effort – a “good catch” program, implement a new “CUSP Team”, announce an upcoming “Safety Culture Survey”, etc.

Several available toolkits can support improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also suggest you consider consumer involvement to ensure a successful week. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement events and programs during Patient Safety Awareness Week:

Visit for more information and resources about #PSAW2017.

CPS FREE WEBINAR: Leadership, Louder than Words: C-Suite Ambassadors of Patient Safety

Committed c-suite leadership to inspire a shared vision is the most critical element in a successful patient safety program. This non-delegable responsibility sets the example by supporting an open and transparent environment, fostering a patient safety culture among all caregivers.

Learn how senior leaders use these steps to provide and support a safer care venue for all patients:

  • Assessing the Culture
  • Integrating patient safety into your strategic plan
  • Supporting your patient safety plan
  • Improving your care processes
  • Sustaining the gains with redesign and high reliability

Thursday, February 16 from 12-1 pm (Central)

To Register, Click Here.

FREE WEBINAR – Safety Culture Assessment for LTC

Culture impacts everything we do. And it’s no different in health care organizations. The strongest cultures support employee engagement, promote open communication and the sharing of mistakes to foster improvement.

Learn about how the Center’s administrative survey can save you time and money and why measuring your culture is so important to improve patient safety.

Webinar – Tue, Nov 1, 2016 1:00 PM – 2:00 PM CDT

Register Here!

Focusing on Both Deaths and Harm from Medical Errors

Focusing on Both Deaths and Harm from Medical Errors

In his latest post to the “Line of Sight” blog, IHI President and CEO, Derek Feeley, reflects on the controversy and criticism surrounding a recent British Medical Journal article, which asserts that medical errors would rank as the third leading cause of death in the US if government calculations included these errors. Feeley welcomes the debate on how best to calculate the number of lives lost as a result of such errors, and he proposes that focusing on preventable deaths is necessary but not sufficient. It’s equally important, he says, to better understand and address the myriad types of preventable harm patients suffer from medical errors.

Cultural Transformation

A study completed at The Ohio State University, and published in the American Journal of Medical Quality, shows a patient safety cultural transformation after implementation of Crew Resource Management.  AHRQ’s Survey of Patient Safety (SOPS) tool was used to measure progress of the culture improvement.  The Center for Patient Safety offers low-cost, high-value administration and department-level analysis of the AHRQ safety surveys.  Contact us!


CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

What the AHRQ guidance means for providers and their patients. 11

Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

New CPS report seeks to raise awareness of safety concerns in the EMS community. 16


  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

Second Victim Study: Research Volunteers Needed!

Are you a clinician who has been part of an adverse clinical event? Did it lead to a career transition into a new role or position? If you answered yes, your insight is needed!  Researchers at University of Missouri Health Care and University of Massachusetts‐Boston are seeking clinicians to participate in a short online survey about the impact of adverse clinical events on career transitions. The survey takes about 10 minutes. Responses are anonymous and confidential. You can take the survey by clicking this link.

Culture Measurement as Key Improvement Tool

A success story from Cox Health

The survey of patient safety culture has become a key improvement tool for CoxHealth, a health system across 5 campuses with 954 licensed beds. CoxHealth spans 83 clinics and serves 25 counties across southwestern Missouri. They have used the survey administered by the Center for Patient Safety (CPS) since 2010. All clinicians in the inpatient and outpatient settings as well as the clinics and EMS agency are encouraged to participate. While participation is a challenge, it has steadily increased over the years to 47% average due to improved communication. The surveys are discussed in the corporate newsletter as well as at leader meetings. Senior leaders discuss the surveys with staff during their regular rounding and encourage participation.

Download this article in the full Fall 2015 Newsletter.


Survey results are aggregated and distributed by CPS, including department level reports for those units large enough to ensure anonymity. Vice presidents and department leaders are responsible for discussing results at staff meetings and identifying opportunities for improvement. Departments using the TeamSTEPPS module use the survey results to identify needs and focus education. Rachel Wells, Patient Safety Officer, advised, “The survey is used as a tool. It helps open the door for us to guide patient care departments and can assist them in focusing their priorities.”


There have been many successes at CoxHealth!

  • The Radiation Oncology department had significant improvement, going from zero survey areas scoring above the 90th percentile, to seven survey areas above the 90th percentile in the last survey.
  • The overall non-punitive response to error score was above the 90th percentile in 2014, which shows a high level of staff trust with management. Patient safety culture has been nurtured as management is supportive and consistently improves processes when opportunities are identified. Jeff Robinson, Radiation Oncology Director, reveals, “Safety Surveys tend to turn the invisible into the visible. Once we saw where we are at, we came together to make the needed improvements.”
  • Cox Monet Hospital stands out as a benchmark within the system. It is a critical access hospital, and the staff’s access to senior leaders is outstanding. When opportunities for patient safety improvement are identified, teams work together to make improvements, which are communicated across the hospital to close the loop. The system is working to replicate this workflow model across all facilities.


Wells’ words of advice based on her experience with the culture surveys: “Patient safety is a journey and the survey is a tool to measure our progress and help us focus along the way. Doing the survey once is not enough. It needs to be routinely offered to see how we’re doing.”

Congratulations to CoxHealth for their focus and improvements in patient safety!


For more information, contact the CoxHealth Office of Patient Safety at 417-269-6589.


PSO Legal Update: A new focus on reporting:

The Center for Patient Safety’s staff has been fielding a lot of questions about what information can be protected under the Patient Safety and Quality Improvement Act and how that relates to reporting t

CPS Releases PSO Report: #CultureForward:

The Center for Patient Safety, a Patient Safety Organization (CPS PSO), is pleased to present this report summarizing some of the information we are learning from the collaborative participation of healthc

CPS Releases Annual Report:

The last two years were a rollercoaster of change! But the passionate team of staff at the Center for Patient Safety (CPS) was on onboard to embrace all of the changes and use them as a rare opportunity to

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.