Changes to Improve Patient Safety Don’t Always Work!

December 2, 2015    |   By: Calevir

The familiar evaluation step within improvement cycles is still necessary in all areas, including patient safety.  Tall Man lettering was adopted by the Food and Drug Administration and was widely used beginning in 2007, however, an analysis now reveals the frequency of errors has not changed since the Tall Man lettering has been implemented.  This evaluation has determined a necessity to explore other options to reduce the mistakes occurring from look-alike and sound-alike drug names.   Read the article.


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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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.