August 12, 2011 | By: Calevir
Almost 8,000 total sentinel events have been reported to TJC since 1995. The majority of reports were submitted by hospitals (64%), 62% of the total reports resulted in patient death, and the most prevalent types of events reported through this voluntary reporting system are wrong-patient, wrong-site, or wrong-procedure, and unintended retention of a foreign body. Leadership, human factors and communication were identified as the most frequently identified root cause of such events.
A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour
The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis
Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with
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.