OIG Report Highlights Adverse Events in LTC

The OIG report, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries[i]” has made quite a splash.   Of course, the Center for Patient Safety is excited that it recommends increased participation with Patient Safety Organizations.   But the report is a treasure trove of good information that can help to support safety efforts and QAPI program development.

The report found that 15% of Medicare SNF residents have preventable adverse events that cause greater than temporary harm.   In addition, 11% of residents had temporary harm.     The OIG used a trigger tool to help them identify medical records that reflected adverse events.   The report contains a good discussion of trigger tool methodology.

Administrators and directors of nursing should consider reading the report, which is less scary than it looks at first blush.   Here are some impressions:

  • There is one clear limitation to the report. First, the OIG only looked at Medicare residents in the first 30 days of their stay, and then only looked at the first 30 days of care.   This probably minimized the number of events they found.
  • On the other hand, it has some other powerful information, both in the data it contains and the light it sheds on HHS’ (and CMS’) thinking about adverse events, Patient Safety Organizations and QAPI.
    • The trigger tool itself and the description of its use can shed light on how to identify those unreported things in your home that surveyors will probably be looking for.   This supports QAPI’s requirement to identify areas for improvement.
    • The description of how the authors and their physician experts distinguished preventable and non-preventable events offers tremendous insight into how providers can evaluate and document the preventability their own events.   For example, the report did not consider pressure ulcers preventable if all recommended evidence-based care was delivered or attempted, AND the ulcer developed anyway due to co-morbidities that made evidence-based care difficult to provide or ineffective.
    • LTC providers need to improve identification and reporting of adverse events so that they can be studied and prevented.   The report recommends participation with Patient Safety Organizations to help accomplish that goal, and to allow for broader study and learning.
    • CMS needs to develop methods to encourage and the identification of events and the implementation of improvements.   Expect this to be a survey focus going forward.   The detailed information in the report about events it identified

The report is available at https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp.  The trigger tool is included as an appendix in the report.   More information about the Center for Patient Safety’s Long-Term Care PSO services can be found at www.centerforpatientsafety.org/ltc-pso.


Babies Switched in Hospital – Nurse Fired!

Doug Wojcieszak of Sorry Works! shares an interesting blog regarding a mistake made at a hospital in Texas where babies were given to the wrong mothers.   DNA testing assured the parents had their correct babies, but the nurse was fired. We don’t know the details, but consider the harm done to the nurse as well as the hospital.  Do you think their employees are willing to report future errors or near misses?  Read more

Adverse Events from Robotic Surgery – Under-reported?

The FDA is evaluating its system for reporting of device-related events based on concerns of under-reporting, specifically of robotic surgery related adverse events.   Studies reveal most of these events are not reported until after some type of legal action occurs.   The ideal is to identify these events when they occur, in time to take preventive action and to report those events so an analysis can be performed and prevention efforts shared across the industry.   Read more

CPS Faculty for National Webinar Series: PSO? PSES? PSWP? You have questions we have answers!


The Center for Patient Safety staff has learned a lot about providers’ needs in working with a Patient Safety Organization (PSO) and setting up processes to gain the most out of PSO participation and related federal confidentiality and security provisions. We are now sharing this expertise nationally through a FREE Webinar Series, PSO? PSES? PSWP? You have questions, we have answers beginning Thursday, September 12 at 11:00 AM CST, in partnership with Verge Solutions!

The September 12 Webinar focuses on establishing a Patient Safety Evaluation System (PSES) and introducing Patient Safety Work Product (PSWP) to help providers better understand how to set up a PSES to best meet their needs, particularly in light of the pending January 2015 ACA requirement for larger hospitals to establish a PSES. If you want to learn more about PSOs, PSES and PSWP, please join us September 12th.

Registration is available here.

Recordings Now Available for National Patient Safety Speakers!

Did you miss our live conference during Patient Safety Awareness Month in March?   It’s not too late to bring these nationally recognized speakers to your organization!   Hot patient safety topics from top speakers in the field:   Dr. Robert Wachter, James Conway, Second Victims, The Emily Jerry Story, and more!

Take advantage of this opportunity and continue the focus on patient safety 24/7/365!

Select from one or more   sessions and receive downloadable recordings to use for training, at your next safety meeting, or to distribute house-wide at your organization(s).   There is no limit to the number of times each recording can be viewed!!     Find out more!

Growing EMS Safety Culture, Center's 2013 EMS Conference

“We [the EMS industry] need  a unified message on safety,” was a key message tying together several presentations at the Center for Patient Safety’s 2013 EMS conference held on May 7th in Columbia, Missouri.

This year’s fourth annual event brought over 80 attendees a variety of updates and ideas about safety culture in EMS at national and local levels, from the broad-based need for an industry safety culture being developed through the National Culture of Safety Project; learning to recognize expertise and its influence on perceptions of safety; understanding that “you can’t be curious and angry at the same time,” to perform unbiased event investigations; and learning about one agency’s success at identifying medication errors, and how they have changed their system for administering medications.Comments from attendees included:    This conference featured some of the best speakers that I have heard in a long time”; “The topics presented were useful, relevant, and interesting”; and “I will be taking a hard look at medication errors.”

Visit our conference web page for downloads and recordings!!

The Second Victim Experience: Train-the-Trainer Workshop in June

The Second Victim Experience:   Train-the-Trainer Workshop
Presented by Sue Scott, RN,  MSN and Laura Hirschinger, RN, MSN

The Center for Patient Safety is pleased to offer this unique workshop on June 11, 2013 to learn and teach the skills to support staff members and physicians who are impacted by adverse and/or unexpected clinical outcomes. Participants will gain insights into the “second victim” experience as well as supportive interventions from faculty who developed and implemented the University of Missouri Health System’s successful “second victim” program. Participants will also acquire the knowledge, skills and techniques necessary to implement a “second victim” program for peers at their organizations.

Space is limited to 40 participants and will be made available on first come first serve basis.  


  • To discuss the ‘second victim’ phenomenon
  • To describe the various stages of second victim recovery
  • To identify and reflect on several second victim events
  • To recognize high risk clinical events which could expose clinicians to the ‘second victim’ phenomenon
  • To identify various interventional strategies to support clinicians experiencing the ‘second victim’ phenomenon
  • To identify and practice ways to initiate a crucial conversation with a second victim
  • To describe the various steps necessary to deploy a support team

DATE: June 11, 2013
TIME:   8:00 AM to 4:00 PM (registration and continental breakfast 7:30-8:00 AM)
FEE: $375 per person (continental breakfast, lunch, and snacks included)


7th Annual Conference Bringing National Speakers!

National Speakers – Important Topics!

Join us in March 2013 as we recognize Patient Safety Awareness Month with a series of five “live & interactive” virtual conference sessions, each centered on important safety topics and presented by national speakers. You choose your combination of 90-minute sessions throughout the month of March, or attend them all!

We’re excited to offer this new and virtual format so you can share the experience with colleagues! Although we’ve altered our format from past conferences, we’ve not swayed from our commitment to providing high quality presenters for important safety topics. One registration now allows an unlimited number of participants at any one location to attend these valuable sessions, so plan ahead and invite others to join! Visit our conference web page to learn more about the conference session speakers and topics.

A downloadable Patient Safety Awareness Recognition Toolkit containing tips and resources to help you easily and successfully celebrate safe care at your organization is also available.   The Toolkit includes ideas for celebrating Patient Safety Awareness Month at your organization and customizable templates for banners, posters, tent cards and buttons to help you spread the word about your organization’s focus on safe care!   Register Today!

3rd Annual Missouri EMS Patient Safety Conference

On Tuesday, May 15, the Missouri Center for Patient Safety sponsored its 3rd annual EMS Patient Safety Conference. More than 60 EMS agencies from across the state of Missouri were represented in Columbia by EMS personnel, gathering to learn the latest information on patient safety topics specific to their field.

Highlights of the day included speaker, Dr. Coy Callison, a leading researcher in communications from Texas Tech, who presented his latest findings regarding communication in the workplace and its important role in patient safety in EMS; Matt Zavadsky, a former paramedic and manager of private sector ambulance services, spoke of the importance of building processes related to vehicle response times and other safety issues in EMS within a “Just” culture. Attendees received a sneak peak at the recently released Just Culture EMS staff training materials provided by Outcome Engenuity. Those who attended received continuing education units.

To find out more about how your EMS agency can improve patient safety, contact Lee Varner at the Center for Patient Safety.

Registration for the Third Annual EMS Patient Safety and PSO Conference is now open!

Are you an EMS provider who cares about patient safety and creating a culture of safety – this conference is for you!

Join us in Columbia, Missouri on Tuesday, May 15th, at the Stoney Creek Inn where you will learn about communication; balancing response times and safety; view the EMS Just Culture staff training materials; and   participate in hands-on work with policies and procedures for submitting information to a PSO.

Register Today!



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.