Winter 2016 Newsletter Released

December 20, 2015    |   By: Calevir

2016 Winter News Cover

Click to download or view on Issuu

On the cover:


Root Cause Analyses (RCAs) are important underpinnings of patient safety. However, thorough investigations of the medical record and intensive interviews with numerous, key staff members are time consuming and often repetitive. But a new University of Missouri Health Care initiative has helped increase effectiveness and accelerate the overall process. 10

Smart Pumps.4 – An article from Citizen’s Memorial Healthcare
C.Diff be gone.6 – An article from St. Luke’s Hospital
Patient Falls.8 – Patient Falls in Missouri
Home Health.9
EMS Update.12
Legal Update: Exciting time for PSO Lawyers.3
Legal Update: Illinois court rules a Contract is Not Enough.14
Calendar of Events.13
Electronic Submission .15
PSO Reporting Trends.16


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.