Our History

The Institute of Medicine’s 1999 landmark report, To Err Is Human, reported as many as 98,000 deaths occur annually due to errors in hospitals with potentially many more deaths due to errors occurring in other health care settings.

The IOM’s report resulted in an international focus on quality improvement and patient safety further encouraged by the IOM’s March, 2001 report, Crossing the Quality Chasm

In 2003, responding to these reports and to growing concerns about medical malpractice rates in Missouri, Governor Bob Holden formed a 16-member Missouri Commission on Patient Safety.

In July 2004, this Commission called for the creation of a new private Missouri Center for Patient Safety to act as a leadership vehicle for patient safety improvements and be a resource for health care organizations, professionals and consumers. This center was to advocate for error reduction, assist in sharing information, identify best practices, develop curricula for professionals and disseminate consumer education materials. It also recommended that such a center serve as a Patient Safety Organization (PSO) should federal legislation be passed defining requirements for such organizations.

Responding to the Commission’s recommendation, the Missouri Hospital Association (MHA), Missouri State Medical Association (MSMA) and Primaris agreed to establish such an organization.

In January 2005, the Missouri Center for Patient Safety was officially established as a new not-for-profit organization in the state of Missouri.

In July 2005, federal legislation followed in the form of the federal Patient Safety and Quality Improvement Act of 2005. Providing a structure for state-based PSOs, the legislation provides protection for physicians and health care providers that voluntarily and confidentially report adverse event data and information to designated PSOs.

In July 2005, federal legislation followed in the form of the federal Patient Safety and Quality Improvement Act of 2005. Providing a structure for state-based PSOs, the legislation provides protection for physicians and health care providers that voluntarily and confidentially report adverse event data and information to designated PSOs. The Center was one of the first organizations to be designated by the federal Agency for Healthcare Research and Quality as a Patient Safety Organization (PSO). As a PSO, the Center began to further support a culture that encourages the reporting, analysis, sharing, learning and prevention of medical errors.

Since it’s inception, the Center has successfully implemented regional projects that continue to have an impact today including a Just Culture Collaborative, and Banding Together for patient safety, projects that were each one of the first in the nation to take culture training statewide and to decrease the potential for error related to the use of colored wristbands across the state. Additionally, the Center has led clinical collaboratives that expand upon our own unique enhancement to the Comprehensive Unit-based Safety Program (CUSP), developed by Johns Hopkins, to improve bedside teamwork and communication.

Beginning in 2012, the Center reframed itself as the Center for Patient Safety (CPS) broadening its vision and mission nationally.

As the CPS, the Center is continually:

  • enhancing its PSO,
  • expanding culture assessment offerings, including the development of culture surveys for EMS and home care,
  • developing innovative educational programs,
  • create shared accountability models that drive transparency and encourage reporting of errors that will result in learnings,
  • and provide many free resources to support the global initiative for safer care.

Today, CPS is one of the largest and most active organizations dedicated to patient safety, working with healthcare providers across the country and across the continuum of care to reduce preventable harm through programs that Protect, Learn and Prevent.

BLOG:

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

CPS Safety Alert/Watch – Culture can Improve the Control of Multi-Drug Resistant Organisms:

ISSUE:A number of events reported to CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status.Examples include:~Patient with s

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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.