Latest issue of Web M&M released

May 2, 2012    |   By: Calevir

The latest AHRQ Web M&M (May 2012) spotlights the challenges with cross coverage hospital teams, the potential for medication duplication following department transfers, and a central line, overlooked at discharge.

Also, don’t miss a great article “The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety” which highlights the pro’s and con’s of multiple approaches to adverse event reporting.



PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

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

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

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

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

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

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