EMS Safety Culture Assessment Webinar

Culture impacts everything we do. And it’s no different in healthcare organizations. The strongest cultures support employee engagement, promote open communication and the sharing of mistakes. Learn why measuring your culture is so important and how you can do it with the Center’s new EMS culture assessment.

REGISTER for this FREE webinar.

EMS Must Foster Accountability and Trust at All Levels

Take a few minutes and read this article from JEMS magazine.  Developing a just culture or a model of shared accountability can offer improvements for greater patient and provider safety.  Likewise, consider measuring the safety climate or culture with a validated tool. Read article.


CPS Safety Watch/Alert: Patient Destination Decisions

Thousands of patients are treated and transported by EMS to a destination hospital every day. Most hospitals can meet the required needs of EMS patients; however, patients who have certain conditions, i.e. Stroke, STEMI, Trauma or Pediatrics, often require more specialized care as quickly as possible. These patients have time sensitive conditions called Time Critical Diagnosis (TCD).

TCD is about:

  • Early Identification
  • Appropriate Treatment
  • Appropriate Destination

Many EMS leaders, hospitals and other stakeholders have adopted the TCD concept of. This approach allows for specialized treatment when minutes matter. (more…)

CPS Safety Watch/Alert: EKG strip

Safety Watch - buttonThe Center for Patient Safety is issuing a PSO Watch in regards to documentation/chart accuracy. An event was shared where there was confusion regarding the appropriate identification of a patient’s EKG strip, resulting in a patient being treated for a dysrhythmia they did not have. This event brought to light many difficulties currently faced by hospitals and EMS providers:

  • Many hospitals are still in the process of transitioning from paper charts to electronic charts, causing confusion with processes.
  • In the hospitals, most units have systems that automatically print patient labels, or have patient names on EKG strips.
  • The ED departments and EMS agencies have very different systems to label orders/tests/blood work/EKG strips which causes confusion and communication breakdown.

To improve accuracy of patient documentation and communication between departments, CPS recommends the following:

  • Review processes for labeling documentation, and labeling placement, in the chart
  • Ensure standardization of processes
  • Reach out to other departments to ensure processes are standardized throughout system
  • Utilize standardized tool for communication/handoff of patient and test results

CPS Releases EMS: PS-10 Moving #EMSForward


Emergency Medical Services (EMS) is a special and unique profession with many dedicated men and women. These professionals bring compassion, enthusiasm and dependability in often very challenging environments. CPS is here to support EMS professionals and offer resources as well as tools to improve safety.

The Center for Patient Safety (CPS) is here to support EMS professionals and offer resources as well as tools to improve safety. The EMS: PS-10 provides ten topics to begin the discussion of patient safety.

At CPS, our focus is on learning what medical errors occur, why they occur and how to prevent patient harm. We emphasize the importance of a culture that promotes safe systems and safe individualized care, as well as strong teamwork and communication.

This report is consistent with our mission and focus as we support and promote safety in EMS. Together, we will help move #EMSForward. We invite you to engage in the conversation further on social media and watch for additional content to support the #EMSForward campaign!


CPS EMS Patient Safety Conference Recap

ems conference webpage header

SAFETY was the message at our Annual EMS Patient Safety Conference in Saint Louis, Missouri.  A one of a kind event that gathers EMS leaders, providers and medical directors to learn, listen, and participate in safety centered activities.  This year was no exception as national experts spoke about some of the most pressing issues facing EMS today.

The day started with an EMS medical director’s breakfast that focused around developing “Safety Huddles” or meetings that would allow for sharing and learning while maintaining the privileges found with Patient Safety Organization (PSO) participation.  Dr. Alexander Garza kicked off the conference with a presentation called “Transforming Quality in EMS” which focused on several key areas including the current state of data in EMS and how it will drive future medical care and policy.  Allison J. Bloom Esq. followed about PSO Hot Topics that are influencing EMS and the importance of participating with a PSO  to protect data.  Fatigue is a major concern in EMS. Dr. Daniel Patterson had a compelling presentation about how fatigue affects EMS providers. The afternoon began with a Just Culture breakout session with Mark Alexander for non-participants, while PSO participants engaged in case studies and analysis of de-identified adverse events for shared learning and best practices. Dr. Peter Antevy finished the day with a presentation about pediatric complexities and EMS.  The presentation focused on the obstacles and strategies to prevent pediatric mistakes for EMS providers during pediatric encounters.

The Center’s staff included various updates, current safety watches, data around adverse events, near misses, and unsafe conditions in the industry.  Lee Varner shared several key accomplishments in 2015 including a collaborative effort with Washington University School of Medicine and the National Registry of EMT’s on the development of a survey tool to measure safety culture. In early 2016, the Center will release a T-10 report featuring the top 10 areas of safety concern in EMS. The report will include resources and education to draw awareness.

The Center for Patient Safety is a private not for profit organization that works across the continuum of care to improve quality as well as greater patient and provider safety.  Contact us for additional information!

EMS Quality & Patient Safety – Free Learning Series
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

Technical Service Bulletins for EMS Cots and Securing Systems

The Center for Patient Safety would like to share two recent Technical Service Bulletins for ambulance cots and securing mechanisms. Please take a moment to review this important information to insure patient safety and crew safety.

Styker TSB 8-2015

Ferno TSB 7-2015




CPS Safety Watch/Alert: Missing & Lost Equipment in EMS

Attention EMS PSO Participants:

Safety Watch 08.25.2015The Center for Patient Safety is issuing a PSO Watch for Missing Lost Equipment in EMS.
Missing and lost emergency equipment is a common occurrence in EMS as indicated by events recently reported to the CPS PSO and concerns voiced from EMS leaders. Without the proper equipment immediately available, unnecessary harm might reach a patient. The Center for Patient Safety is issuing this Safety Watch to remind EMS providers and leaders about the potential risks associated with missing equipment. This is a call to action to prevent risk and patient harm.


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.