ISMP LTC AdviseERR Addresses Distractions and Interruptions

October 10, 2014    |   By: Calevir

CPS has given the ISMP’s LTC AdviseERR shout outs in the past.   We also talk a lot about distractions and interruptions as one of the most widespread causes of mistakes.   ISMP takes on the distraction issue in its latest issue of its long-term care medication safety newsletter, available here.   This issue speaks to the scope of the problem and has some great suggestions for controlling it.   Subscribe to the newsletter.


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

Read More


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.