Emergency Medical Services Agenda 2050. How do see the future of EMS?

The EMS Agenda 2050 “Envision the Future” Straw Man document has been released to the public for comments to guide the future direction of EMS.  The document is a comprehensive and robust body of work with a wide range of topics, all of which are important to the EMS profession.

The Center for Patient Safety (CPS) was founded in 2005 and shortly thereafter began working with EMS.  Over the years we have worked to raise awareness and offer creative solutions around patient safety.

Since our work at CPS is a specialized area of healthcare we are excited to see that the Technical Expert Panel has included a section on patient safety in the Straw Man document.  The document doesn’t merely mention the importance of patient safety but includes 9 areas that focus on the topic of patient safety and developing a culture of safety.  In addition, the areas listed offer innovative and actionable steps for EMS leaders to implement for the reduction of preventable harm.

Today, we see an opportunity to create action and change in the EMS profession regarding patient safety.  Please join us in reading the Straw Man document and then comment on it to let your voice be heard.  CPS will be advocating for the steps listed in the document and welcome your insights on this valuable document-with your input we can effectively address the issues surrounding patient safety.

To learn more about EMS Agenda 2050 and read the Straw Man document use this link.


Do you have an EMS Patient Safety Plan?

While we have all heard the old saying, “do you plan to fail or fail to plan,” this short statement has likely influenced many people to re-evaluate a current process or situation in their life.  The specialty area of preventable harm or patient safety is gaining strong momentum in Emergency Medical Services, which has relied on another common old saying “do no harm”.   While the desire to do no harm has always been present in EMS, it isn’t until recently that coordinated efforts have come forward to inform, organize and delineate actionable plans and steps to reduce preventable harm at the organizational level.

The EMS Patient Safety Boot Camp is a great way to get started, or to improve your current patient safety journey.  An opportunity in beautiful, cool Denver is waiting for you!


EMS Week Spotlight: Lee Varner

The Center for Patient Safety is proud of our diverse team and is especially proud of our Patient Safety Director, Lee Varner, MSEMS, EMT-P, CPPS. Having spent much of his time in EMS throughout his career, he now enters his third year with the Center in a supporting role. He is a valuable resource to all of our participating organizations. We recently sat down with Lee and asked him a few questions…

Q: What first interested you in healthcare?
I’ve always had an interest in science but it wasn’t until I took an EMT class that I made a connection between science and helping people.  From there I then went on to paramedic school and worked in various roles in EMS but some of my most rewarding years were working as a frontline paramedic.

Q: Why is patient safety important to you?
I find the topic of patient safety extremely interesting, specifically, understanding why mistakes occur in healthcare.  This in turn has offered me an opportunity to learn about new principles, philosophies and concepts and then how to apply them to EMS. 

Q: What do you miss most about working on the front lines (or in a care setting)?
I still live in the same community where I worked as a paramedic.  When I see an ambulance I always look to see if I know the crew  and wonder what type of call they might be running on.  I think it was that “wonder”  that I miss the most as you never knew what to expect one duty day from the next as each day was always different.  Some shifts operated at a very high level of intensity that might leave you drained physically, mentally and sometimes emotionally.  But I found it was the teamwork and coordinated efforts of everyone working together to help others very appealing.  

Q: What do you enjoy most about working at the Center for Patient Safety?
There are many areas I find rewarding, one of which is being part of a such a committed team .  In addition, the opportunity to always be learning from each other as we all come unique backgrounds in healthcare.  I also appreciate the culture of the Center as we truly practice what we preach when it comes to working in a culture that supports a model of shared accountability.  It’s a learning environment where we are always focused on improving the quality of our services that to the many organizations that we work with.  

Q: Based on your experience in the healthcare provider setting, and your experience at the Center, what is your message to other [nurses/LTC/EMS/Hospitals]?
As a provider, working day in and day out it’s easy to forget the positive impact that you make in people’s lives.  Recently our local  EMS responded to a family member and I was so thankful to see them.  My message is to never underestimate the difference you make in peoples lives.   

Q: What is your greatest achievement around patient safety (either in a previous job or current job)?
I would have to say it’s been the EMSFORWARD safety campaign that we started last year.  The project has been a collaborative effort at CPS so I can’t take all the credit but more importantly it’s been rewarding to watch it grow and gain more attention

Q: What was the last book you read?
The last book I read was “Talk like Ted”, the 9 Public Speaking Secrets of the World’s Top Minds by Carmine Gallo.  The book offered me a lot of inspiration in the development of patient safety content and material as we work with EMS

Q: Who do you admire?
I admire the many EMS professionals who are out there working every day  behind the scenes often with little recognition or support. 

Q: Anything else you’d like to share – interesting tidbits about where you’ve lived, where you’ve worked, about spouse, children or grandchildren, etc?
My wife and I recently downsized and moved to a town home on main street in Saint Charles, Missouri.  We are close to the Katy trail where we can bike and run as well as enjoy the many activities taking place in the community.

It’s Time to Begin Your Journey to Improving Patient Safety and Quality in Healthcare. Are You Ready?

At the Center for Patient Safety (CPS), we feel strongly about culture being an integral part in the journey to improving patient safety and quality in healthcare. Improvements are not immediately achievable, but it’s never too late to begin the journey!

CPS encourages the use of survey assessments as a diagnostic tool to support and guide your patient safety culture improvement efforts. CPS can efficiently administer your culture survey, saving you valuable time and money.

CPS administers custom patient safety culture surveys for:

Click here to learn more about how CPS’s Safety Culture Survey Services support and guide patient safety and quality improvement efforts.

Ready to start your journey? You can also request a no-obligation estimate for your organization here.


They say the only constant thing in life is change, and it’s no different at the Center for Patient Safety (CPS). Since the first IOM report was released in 1999, patient safety concerns have been in the spotlight, and the CPS was created to address the issues in that report confronting healthcare. Since we opened our doors in 2005, we have supported thousands of organizations across the country with their patient safety programs; and now, years later, we continue our mission. I assumed the position of Executive Director of CPS in July of this year, and it has been an incredible journey. What appealed to me most about the opportunity to lead CPS is the ability to energize, engage, and inspire health care providers across the country, and throughout the world, to reduce avoidable patient harm. Our team has been hard at work this year, developing some of the most innovative concepts ever to reach the front line staff, and I can’t wait to share them with you. Our team has so much to offer the healthcare community. The energy that comes from the clients and providers we work with through CPS daily is absolutely amazing! Each provider is dedicated to promoting patient safety in their organization. They are driven by compassion and a selfless desire to improve care. They are an inspiration to our team and to their communities.

I invite you to be an active participant with the Center for Patient Safety in a manner that best fits your abilities:

• Host a patient safety boot camp in your region
• Join us for any of our ongoing educational webinars
• Share a success story and best practice in our newsletter
• Be a part of our PSO to share and earn protections
• Be a sponsor for an organization or program
• Ask us about our culture improvement opportunities
Each person that contacts us has their own barriers, concerns, and issues that keep them up at night. Many of these issues are some of the same things our team dealt with during their many years of experience. Our team knows how you feel, and we know how to help. This will certainly be an exciting time as CPS continues to grow and improve culture and patient
safety across the country. We strive for excellence in our delivery of services, which is achievable through our revised mission of providing creative culture solutions to improve patient safety. Join our mission today by following us on LinkedIn, Facebook or Twitter, or contact our office to find out how you can engage with CPS today!

NAEMT and CPS Collaborate in Report – Patient Safety in EMS

The Center is excited to be part of the most recent NAEMT report, Patient Safety in EMS, which helps the EMS community understand the role of Patient Safety Organizations (PSO’s) in supporting an environment in which patient safety issues are reported and used as a basis for improvement and policy change.

Read the report!

Let Verge Health and the Center for Patient Safety help you meet the January 1, 2017, CMS requirement with ease.


Let Verge Health and the Center for Patient Safety help you meet the January 1, 2017, CMS requirement with ease.

Join one of these webinars:
Hospital PSO 101, December 15th at 2:00pm ESTverge-1215
EMS PSO 101, December 15th at 3:30pm EST (EMS agencies can join a PSO too!)

The Center for Patient Safety will share information and answer questions on how joining a PSO can help you improve patient safety at your organization:

  • What are the benefits of joining a PSO?
  • How can a PSO support your patient safety efforts?
  • How can PSO protections apply to your organization?

Who should attend?
Healthcare professionals with a desire to improve patient safety and reduce patient risk, including professionals and leaders working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants.

Why join a PSO?

  • Protect. A PSO offers federal confidentiality and privilege protections of the Patient Safety and Quality Improvement Act of 2005 to all licensed health care providers.
  • Learn. Working with a PSO offers sharing, learning and educational opportunities.
  • Prevent. A PSO recommends proactive measures from lessons learned to assist in the prevention of future adverse events.

Who can participate with a PSO?
Any licensed provider can participate with a PSO.  CPS works with providers across the continuum of care, including hospitals, health systems, medical offices, ambulatory surgery centers, emergency medical services, nursing homes, home health and hospice, and pharmacies.

CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

What the AHRQ guidance means for providers and their patients. 11

Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

New CPS report seeks to raise awareness of safety concerns in the EMS community. 16


  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

Free Webinar – PSOs: What you should know!

pso-whatyoushouldknowThe Center for Patient Safety is hosting a series of free upcoming webinars to share information and answer questions on how joining a Patient Safety Organization (PSO) can help you improve patient safety at your organization. Each webinar is available for providers in different healthcare settings, including medical offices, ASCs, LTC, EMS, and home care. A hospital-specific webinar was held in April but will be available again in the Fall. Contact the Center for more details.

Each webinar will help organizations and providers:

  1. learn the benefits of joining a PSO
  2. learn how joining a PSO can support your patient safety efforts
  3. learn how PSO protections can apply to your organization

Medical Clinics and Ambulatory Care
5/19/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in medical offices, physician groups, and ASCs with a desire to improve patient safety and reduce patient risk, including professionals working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants for medical offices, ASCs or health systems.

Long Term Care
6/9/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in LTC with a desire to improve patient safety and reduce patient risk, including professionals working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants for long term care or health systems.

Emergency Medical Services
6/16/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in EMS with a desire to improve patient safety and reduce patient risk, including chiefs, managers, patient safety leaders, and legal staff, executive leaders, and outside counsel and consultants for EMS.

Home Care
9/8/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in home care (home health, hospice, home and community-based services and private duty) with a desire to improve patient safety and reduce patient risk, including professionals working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants for home care.

CPS Safety Watch/Alert: Intranasal Medication Administration

Safety WatchBased on industry data and recent findings from event data submitted to the PSO, the Center for Patient Safety is issuing a Safety Watch about intranasal medication administration.


Recently, an EMS provider mistakenly administered a medication intranasally when it should have been administered by IV route only. There were was no harm reported to the patient, however, the patient didn’t receive the therapeutic effects desired. This safety watch is to remind providers that not all medications are approved for intranasal administration and dosing can be different from other routes.

Intranasal medication administration is a safe and effective means of administering medication. This administration procedure offers many benefits including ease in administration,rapid absorption and no requirement for intravenous access. On a daily basis, EMS professionals use the intranasal route to save lives and reduce pain, however, not all medications can be administered intranasally.

An incorrectly administered medication can occur at any time, however, most medication errors reach the patient when there is no crosscheck process.

To mitigate and prevent future events, the Center recommends that the five medication rights be followed. In addition, develop a process to support providers with a cross check or medication read back procedure. Always follow medical direction and established protocols. As with all medication administration, the provider should insure the five rights:

  1. Right Dose
  2. Right Patient
  3. Right Route
  4. Right Time
  5. Right Drug

Therapeutic Intranasal Drug Delivery – http://intranasal.net/
Sedgwick County Medication Cross Check Video – https://www.youtube.com/watch?v=qktIdQ86piI


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.