JAMA Article Suggests Hospital Program Leverages Penalties Against Higher Quality Hospitals

This article is an interesting study on quality measurement in hospitals in light of government penalties based on Hospital Acquired Conditions (HACs). Findings suggest the HAC Reduction Program merits reconsideration to ensure it is achieving intended goals to improve the quality of care. Read article.

CDC Reports

On March 26th the CDC released two reports that together show the progress that has been made to eliminate infections in hospital patients, and that more work on patient safety is needed.

The first report is a New England Journal of Medicine providing national healthcare associated infection estimates, stating that, on any given day, 1 of every 25 patients had 1 or more infections related to their hospital stay.   This equates to around 722,000 infections per year, and of those, 1 of every 9 patients will die from these infections during their hospital stay.

The second report is an annual report toward the U.S. Health and Human Services HAI prevention goals, which provided both state and national progress toward these goals.   Nationally, there has been a 44% decrease in central line-associated bloodstream infections from 2008-2012; a 20% decrease in surgical site infections (related to the 10 surgical procedures tracked) from 2008-2012; and a 3% increase in catheter-associated urinary tract infections.

For more infection and to access the reports, visit:   www.cdc.gov/hai

Kudos to Swedish Covenant Hospital

Swedish Covenant Hospital has been named as one of the safest hospitals in America, the only one in the Chicago area. They have successfully reduced their hospital-acquired infections, including central line, surgical site and catheter-related UTI’s. Next they will focus on fall prevention.  Patient safety is driven by leaders from the Board level down, and employees know they have permission to ask why things are done without criticism.  Learn more

CPS Safety Watch/Alert: Meningitis from Steroid Injection Medication

Meningitis from steroid injection medication continues to be a concern with 205 cases in 14 states, resulting in 15 deaths thus far.  The medications were distributed to 23 states. The CDC provides the details and the latest information:  http://www.cdc.gov/HAI/outbreaks/meningitis.html

Multistate Fungal Meningitis Outbreak Investigation.” Centers for Disease Control and Prevention; dated 15 Oct, 2012. Web.  http://www.cdc.gov/HAI/outbreaks/meningitis.html


2012 Partnership in Prevention Award for reduced infections – Application deadline: August 1

A national award has been created to highlight and promote the work of one hospital that has achieved sustainable improvements.   Based on the concepts of the “National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination,”   the 2012 Partnership in Prevention Award is available to any hospital that meets the eligibility criteria and can show evidence of success in reducing infections.

The application deadline is August 1 with award announcement in October.   Find out more in this Infection Control Today article, or visit APIC’s Partnership in Prevention Award page for more details, and to apply.

Primaris Taps the MOCPS to Lead CUSP Training Program

MOCPS is pleased to announce that Primaris, the federally designated Quality Improvement Organization (QIO) for the state of Missouri, has asked us to lead the Basics of Comprehensive Unit-based Safety Program (CUSP) training program for seven hospitals as part of a CAUTI training project.  We are honored that Primaris has recognized our expertise with CUSP and success in working with hospitals to implement it successfully.  The Basics of CUSP is part of the Center’s People, Priorities and Learning Together initiative.

Commonwealth Reports On Hospitals Reporting No CLABSIs in ICUs

This new report from the Commonwealth Fund offers lessons from hospitals that have not experienced any central line associated blood stream infections in their ICUs in 2009.   These lessons include following evidenced based protocols, importance of a dedicated team overseeing central line insertions, value of participation in national and statewide collaborative, and the need for continued monitoring of infection rates and maintaining communication with staff about rates and goal achievement.

MOCPS Co-Hosts CUSP/Stop CLABSI Mid-Course Meeting in Topeka, Kansas

The Kansas Healthcare Collaborative, along with the Missouri Center for Patient Safety, co-hosted the Cohort 5 & 6 CUSP/Stop CLABSI Mid-Course meetings in Topeka, Kansas this week!   Over 30 teams from Kansas and Missouri were in attendance and participated in group work on overcoming project barriers and walked through the process of learning from a defect.

Several Missouri teams were recognized for completing 6 or more consecutive months without a CLABSI in 2011, and teams from Cohort 2 in the Greater Kansas City area were recognized for completing the two year project.   Congratulations to all the Missouri teams!

MOCPS Leading CUSP Education in National NICU CLABSI Collaborative

The MOCPS has been invited to lead a six-month course on the Comprehensive Unit-based Safety Program (CUSP) to over 70 Neonatal Intensive Care Units (NICUs) located throughout 7 states.    All participating NICUs have joined a national collaborative sponsored by the Health Research Educational Trust (HRET) to stop central-line associated blood stream infections (CLABSIs).     (more…)

CDC Declares Healthcare Acquired Infections a “Winnable Battle”

At any given time, about 1 in every 20 patients has an infection related to their hospital care. HAIs not only affect patient lives, but also add to our growing healthcare costs.     CDC has identified eliminating HAIs as a winnable battle. With additional effort and support for evidence-based, cost-effective strategies that we can implement now, we can have a significant impact on our nation’s health.

This healthcare-associated infection briefing folder provides a snapshot of the context and background for this priority area, as well as descriptions of some of the systems, policy and programmatic interventions pursued by CDC and our public health partners at the federal, state and local levels. This information will be updated periodically as new data or relevant information becomes available.


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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