Blog Highlights Need for Safety Improvement in LTC and Ambulatory Settings

June 2, 2014    |   By: Calevir

In a recent blog, Olivia MacDonald writes about a recent publication from the OIG with findings that over 20% of Medicare patients experience adverse events during skilled nursing facility stays, 60% of those events being preventable. Hospitalizations resulting from such events cost the Medicare program an estimated $208 million.   She also notes that research by Towson University’s Mary Carter identifies that hospitals have historically made more efforts to understand medical injury than nursing homes and outpatient settings such as doctors’ offices, surgery centers and emergency rooms.   The February 2014 OIG report called upon the Agency for Healthcare Research & Quality to collaboration with CMS to compile a list of potentially reportable events for nursing homes.


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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