AHRQ Patient Safety Primer Released

September 17, 2015    |   By: Calevir

AHRQ has just released a new Patient Safety Primer on High Reliability.  Recently healthcare has become quite intrigued with the concept of high reliability organizations.  These types of organizations understand that concepts of patient safety are not static ideas but rather changing and moving as healthcare changes.  Because healthcare is fast moving with the potential for high level consequences, the idea of utilizing concepts/ideas/processes devoted to becoming a high reliability organization have become quite attractive.  Read the released Patient Safety Primer on High Reliability.


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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