Diagnostic Errors are a Problem!

Diagnostic errors are problematic!  About a decade ago hospital-acquired infections (HAIs) were in the same position, seeming like an impossible health care issue.  But hospitals across the nation have made great progress in reducing HAIs, although there definitely is room for more improvement.  Diagnostic errors are our next challenge.  Read more from Dr. Peter Pronovost, Director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins and Senior VP for Patient Safety and Quality.

LEARN MORE! Center for Patient Safety and Verge Health is hosting a FREE WEBINAR tomorrow!

Physician Engagement: Reducing Diagnostic Errors to Improve Patient Safety
March 15, 2017 1:00pm -2:00pm CDT

Diagnostic errors impact our patients, our providers, and, of course, our finances. We have a responsibility to address the concern. Join this webinar to learn the impact of diagnostic errors and what steps can be taken to help reduce the occurrence of these costly events.

SPEAKER: Michael Handler, MD, is the Center for Patient Safety’s Medical Director. Dr. Handler will address the 2015 IOM Update’s recommendations and the existing physician engagement opportunities that can benefit patient safety at your organization.

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.

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.

CMS Releases New Tools and Launches Initiatives Linked to Patient Safety

CMS has released a new online tool to empower consumers to make informed choices about their health care. The Quality Care Finder links consumers with all of Medicare’s compare tools in one convenient location (www.Medicare.gov/QualityCareFinder). Also released is a revised Hospital Compare website with additional data related to outpatient surgical infections and heart attack care (www.hospitalcompare.hhs.gov).     Dr. Don Berwick, CMS Administrator, states “These tools are new ways CMS is making sure consumers have… important information they need to make the best decisions about where to receive high-quality care.”

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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.