EMS Fall Patient Safety Newsletter

The Center for Patient Safety has released the EMS Fall PSO Newsletter.  We’re certain you’ll find something of interest related to patient safety at your organization!  Download the full newsletter to read more on the PSO legal environment, upcoming events, best practices, and much more!

EMS PSO News – a publication for EMS – Download or View on Issuu

Pilot program launched for EMS behavior health data

The Center for Patient Safety works closely with many EMS services around the United States to improve patient safety and reduce preventable harm. Over the past year EMS leaders have expressed interest to better serve the needs of the mental health population. In the process many of these leaders have discovered there is little data around these encounters and transports. This includes emergency calls or scene encounters as well as inter facility transfers between hospitals.

Therefore, approximately six months ago the Center’s EMS data committee started to explore the opportunity to collect data around these patient encounters. This includes understanding what happens on an emergency scene but also during an inter facility transfer. Recently the committee finalized the data collection formats for this project. Starting this month a pilot program was initiated to collect data and so far participation has been strong.

Why a PSO? Participating with a federally listed PSO (Patient Safety Organization) that works with EMS offers many important benefits. PSO’s were created to support shared learning under the Patient Safety Quality Improvement Act of 2005. A PSO does this with federal safeguards to protect discoverability of event analysis and deliberations. Event information is aggregated and de- identified then shared with participants in various learning opportunities. Many EMS services are hesitant to share data out of the fear of litigation and concern about their public image

The behavior health pilot will collect data around several key areas including provider and patient safety as well as resource utilization. In addition, many leaders would like to understand the frequency and dynamics of specific high risk events such as patient elopement from an ambulance.  Data will also support understanding community’s mental health resources as this often determines the destination for this patient population.

EMS leaders are hopeful that this new area of data collection will help everyone understand the current state more clearly. The Center and its many PSO participants are excited to be involved with this project. Ultimately we hope it drives greater patient and provider safety while we also learn how to save healthcare dollars.

Center for Patient Safety releases Summer PSO Newsletters

The Center for Patient Safety has released the Summer PSO Newsletters.  We’re certain you’ll find something of interest related to patient safety at your organization!  Download the full newsletter to read more on the PSO legal environment, upcoming events, best practices from Hannibal Regional Hospital and Mercy Hospital, St. Louis, and much more!

  • PSO News – a publication for Hospitals and ASCs – Download or View on Issuu
  • EMS PSO News – a publication for EMS – Download or View on Issuu

PSO’s as Standard Operating Procedures

Dr. Jay Reich, EMS Medical Director for the Kansas City Fire Department, presented last week at the EMS State of the Sciences Conference, also known as “The Gathering of Eagles”.   The conference is a unique, and highly respected, conference in EMS.   Each year, the conference offers opportunities to learn about the latest science and advances in EMS, including current research, data and industry innovations.   Those selected to present at the conference are EMS medical directors from the largest EMS systems in the United States.   In addition, other leading experts from around the world present relative information to advance the practice of EMS.

Dr. Reich’s presentation titled “PSOs as SOPs! Getting Patient Safety Organization Buy-In for EMS CQI” shared how participating with a PSO can protect the quality and safety work in EMS, as well as support the EMS medical director.   Since Patient Safety Organizations (PSOs) are fairly new to EMS, Reich outlined some of the benefits of PSO participation, such as, information and key examples of how Kansas City Fire Department is implementing efforts towards greater patient safety and quality improvement. His presentation focused on the ways a PSO supports the EMS shift to proactive efforts to prevent adverse events and unsafe conditions instead of reactive.

Dr. Reich’s full presentation can be found at the Gathering of Eagles website under 2015 presentations.

PSOs as a Risk Management and Compliance Tool

Allison Bloom recently wrote an important article about Mobile Integrated Healthcare (MIH) that was featured in EMS Insider.   If you are providing this care or exploring MIH then you should read Allison’s article and learn more about how participating with a Patient Safety Organization (PSO) can help you.

EMS Services Participating with a PSO can improve quality, safety, & financial performance

Written by Lee Varner, BS EMS, EMT-P
Mike Wallace,
EMS Captain, Central Jackson County Fire Protection District

Does this sound like your EMS service….

Your typical runs include calls for chest pain, shortness of breath, seizures, and even cardiac arrest.  You run these calls day in and day out.  You drop patients off at the hospital just in time to clear for another call.

At the end of the day, ask yourself these simple questions:

  • Do you look back at the calls to determine how well your providers performed from the perspective of protocol compliance or customer service?
  • Do you have performance benchmarks  established, for example time to 12 lead or aspirin administration on chest pain patients?
  • Do you know the percentage of survival for cardiac arrest patients in your community?
  • Do you have a mechanism in place that allows for the self-reporting of events as they relate to medication errors, equipment malfunctions, or near misses?

If you answered yes to all of these questions, great job!   However, some of you probably said no to most.


2014 EMS Patient Safety Conference Success!

The Center for Patient Safety’s Annual EMS Patient Safety Conference was a success!   We had great speakers who brought new ideas and concepts that helped stretch the imagination of those attending.

  • David Williams from the Institute for Healthcare Improvement shared the Plan-Do-Study-Act method for organizational change and success.
  • Tom Judge, Executive Director of Lifeflight of Maine having years of EMS experience, offered practical advice regarding the changes that he has witnessed in EMS.   He also discussed how organizations can utilize a culture of safety to help manage risk.
  • Michael Bachman from Wake County EMS in Raleigh, NC shared his insights and experience regarding the coordination of patient safety using mobile integrated healthcare, focusing on “For the patient, not to the patient”.


CPS Safety Watch/Alert: Cricothyrotomy

Safety Watch
This Safety Watch is to advise you that having multiple different types of cricothyrotomy kits can lead to confusion during an airway emergency. We believe standardizing your equipment including cricothyrotomy kits within an organization or within a region would help to reduce the likelihood of an adverse event.

Cricothyrotomy also commonly called a “cric” is an emergent procedure for establishing an immediate airway.  The procedure can be performed several ways with various commercially prepared kits or with specialty prepared equipment. The skill requires the provider to access the cricothyroid membrane to establish an airway for oxygenation and ventilation.

Possible reasons for these events:

  • Access to different types of kits can lead to confusion during an airway emergency

Protecting, Improving and Preventing Errors in EMS

That was the message shared with EMS professionals at ESO Solutions WAVE 2014 Conference in Austin, Texas. EMS leaders learned about protecting an organization’s safety and quality work as well as how they can safely learn from each other to prevent future events from occurring. The presentation, PSO 101, explains the Patient Safety Quality Improvement Act (PSQIA) for EMS professionals. A Patient Safety Organization (PSO) is a new concept for many in EMS.   If you would like more information or to schedule a presentation, please visit www.emspso.org, contact the Center for Patient Safety at [email protected], or call 1.888.935.8272.

Center releases Fall 2014 EMS PSO Newsletter

Fall EMS 2014The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more!   Download the newsletter or view on Issuu.


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.