CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms


  • 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 suspect TB transferred to floor without making staff aware.
    • Patient transferred to ICU from the ED without sharing information that patient was positive for MRSA.
    • Patient directly admitted without informing receiving personnel that swab testing for influenza had come back positive.

Actionable Items to Mitigate Risk

  • Standardize communication during handoffs.
  • Include in the standardized handoffs a summary of the patient’s infectious disease status, including need for precautions.
  • Identify any outstanding testing during handoff.

The Culture Connection

  • Effective handoffs and clear communication among staff members, within and between units, are important components of a strong safety culture.
  • In addition to investigating the clinical components of these events, the organizations should examine any culture factors that impede full and appropriate communication at handoffs.


Deadly Deliveries Report

USA Today – Deadly Deliveries. Hospitals know how to protect mothers. They just aren’t doing it. -Alison Young

USA Today recently published an extremely sobering investigative report, on the topic of the maternal death rate in the United States. According to statistics, the US number of maternal deaths has increased between 1990 and 2015 while other developed countries have a decreased number of maternal deaths over the same time span. Having been a Neonatal ICU nurse, this article pulled on my heart strings, how could we be letting this happen? But then my inner fact checker came forth and I decided I had to verify these numbers. Maybe it was that the journalists had misinterpreted the reporting, or read some obscure report. Well, while I found other statistics they all pointed to the reality that the US is definitely lagging in the quality and safety of care being provided to pregnant mothers. It doesn’t matter what statistics you use, WHO, UNICEF, or those put forth by the Global Burden of Disease, the US has seen an increase over the past 25 years in the number of women who die while pregnant, during childbirth or within a brief period after having given birth. To highlight the extraordinary nature of this healthcare crisis, I looked at who else had an increasing maternal death rate over the same time period. It was even more sobering. Out of the 183 countries that had data reported, only 12 others also reported an increase in the rate of maternal deaths. The US is in a small subgroup that includes, North Korea, Guyana, Georgia, Serbia, Tonga, Zimbabwe, Venezuela, South Africa, Suriname, Saint Lucia, Jamaica and the Bahamas.

What’s even more alarming in this article titled, “Deadly Deliveries” is that many of these deaths are preventable through basic processes of monitoring and management. So why have we gotten away from simple tasks? This is what I don’t understand. Maybe it was the organization in which I worked, but when I was working in the NICU, there was an understanding, a philosophy, a culture that believed in being pro-active rather than re-active when it came to healthcare. Even if it meant being a bit aggressive in the treatment of these premature babies/critical ill infants, the belief was basically that an ounce of prevention was worth a pound of cure. We would rather anticipate an infant “crashing” so to speak and try to prevent than to wait for them to actually “crash” and then deal with all the repercussion that could result from that. Why isn’t this being followed in all areas of healthcare? I don’t understand.

Ever since the release of the IOM report in 1999-2000, there has been an increased focus on patient safety and quality of care. Reimbursement has been tied to certain safety and quality measures as enticement for utilizing patient safety principles and actively working to promote patient safety. My question is – I’m not certain that we need more quality measures to report so much as we need to be focusing on the patient and making certain that our care is individualized to each patient.

Thinking of Joining a Patient Safety Organization?

There are other factors that go along with identifying high risk patients, some which deal with access, other factors deal with understanding who the high risk populations are. Other’s maybe deal with the education of our healthcare providers, instructing them and providing simulation scenarios to utilize critical thinking skills. That is something that struck me as I read the article, what happened to the critical thinking skills? Healthcare isn’t just following checklists, though they definitely help! But healthcare is understanding the body and understanding the normal variations that each person may have and knowing what is normal for one person may not be normal for another. It’s treating each person individually, with respect and dignity, without judgment on their circumstances.

‘Deadly Deliveries:’ Quality Talk Podcast Examines Rising Maternal Death Rate

There isn’t just one answer to this crisis of decreasing our maternal mortality rate, but as healthcare providers we need to start remembering why we went into healthcare and becoming advocates once again for our patients. Participating in the AIM program and using their safety bundles will help, reaching out to counterparts in the UK, France, Finland and Germany to see what protocols, policies they put into practice to decrease their maternal death rate will also help. Education of our healthcare providers and simulation of potential high risk scenarios will provide experience and utilization of critical thinking skills. But first and foremost, we MUST start focusing on the patient and putting their needs as priority over and above any potential financial penalties. Care plans for the patient must be constantly evaluated and evolving. And my sister nurses need to be utilizing their critical thinking skills to advocate for the best care of the patient. Only then will we begin to see the care of our new mothers improve.

Missouri Board of Pharmacy Regional Meeting

It was an honor to be the key note speaker for the southwestern regional Board of Pharmacy yesterday in Springfield. About 80 professionals enthusiastically learned how they can personally improve patient safety culture whether their setting is retail or hospital based. We discussed the importance of leaders “walking the walk and talking the talk” as actions speak louder than words, and then they learned from each as they shared how leaders can improve their skills. The last discussion was about the principles of high reliability – a perfect goal for pharmacists! Want to learn more? Contact the Center for Patient Safety.


Zero Harm

Zero Harm – that’s the goal for every health care provider!  The only way to achieve this is for patient safety to be embedded into your culture.  That means  organizational leaders make it a priority by “walking the walk and talking the talk”. The culture must change the providers’ thinking from “it’s a known complication” or “it sometimes happens” to “not on my shift!”  Recently the American College of Healthcare Executive and the National Patient Safety Foundation released a whitepaper which provides guidance and tools to advance your organization’s culture of safety.   Whether you are just beginning your journey or are attempting to sustain levels of improvement, click here to downlad the guide which will be useful in directing your efforts and evaluating your success along your journey to zero harm. 


The Joint Commission released Sentinel Event Alert #57

The Joint Commission released Sentinel Event Alert #57 this week:  The Essential Role of Leadership in Establishing a Patient Safety Culture.

The Center for Patient Safety supports the 11 patient safety tenets and provides services and supports to help health care providers across the continuum improve patient safety.  For additional information contact us.

It’s Patient Safety Awareness Week – #PSAW2017

The Center for Patient Safety encourages providers to use the week as a great way to remind the staff and community of their commitment to safety.
It should be a time of celebration of successes, but also a time of reflection.

In recognition of the week, and the efforts that continue every day throughout the year, the Center for Patient Safety is offering a 20% discount on the already affordable safety culture survey services. Download a proposal with sample feedback reports and an online sample survey link. We encourage the use of the survey as a diagnostic tool to assess your culture. Get started today and take advantage of the offering!

Several available toolkits can support your improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also want to remind you that consumer involvement is important to ensure a successful patient safety program. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement your events and programs during Patient Safety Awareness Week:

The Second Victim Experience – Train-the-Trainer Workshop

Most health care providers adjust well to the multitude of demands encountered during an unexpected or traumatic clinical event. Providers often have strong emotional defenses that carry them through and let them “get the job done.” Yet sometimes the emotional aftershock (or stress reaction) can be difficult. Signs and symptoms of this emotional aftershock may last a few days, a few weeks, a few months, or longer.

Program Objectives

  1. Describe the ‘second victim’ phenomenon and high risk clinical events.
  2. Describe the six stages of second victim recovery.
  3. Utilize components of the Scott Three tier model of support to design a plan for your organization.
  4. Develop a plan to deploy peer support team training.


Learning from IHI – How to Speak Up for Safety

The next WIHI broadcast — How to Speak Up for Safety — airs on Thursday, November 17, from 2:00 to 3:00 PM ET, and I hope you’ll tune in.

Our guests will include:

  • Joanne Zee, BScPT,  MSc, MCPA, Senior Clinical Director, Brain and Spinal Cord Rehab Program, Toronto Rehab, University Health Network (Toronto, Canada)
  • Brenda Kenefick, Director, Lean Process Improvement, University Health Network
  • Gregg Meyer, MD, MSc, Chief Clinical Officer, Partners Healthcare System (Boston, MA)


Just Culture Results and Patient Safety Culture Survey

CPS has long believed that Just Culture principles of accountability are a great way to address issues highlighted Safety Culture Survey results.  It focuses on system response, strong investigation and analysis of employee choices so that organizations can improve systems while dealing with their employees in a fair and just manner.

AHRQ, the agency that developed the Survey of Safety Culture, is offering a free webinar, “Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results.”  Though the program primarily addresses hospitals, the principles will apply to any healthcare provider organization.  CPS encourages providers to attend this program and learn more about the survey and how Just Culture can help.

For additional information about the Center’s survey or Just Culture offerings, contact the Center for Patient Safety (888-935-8272) or check out our website, www.centerforpatientsafety.org.

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.


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

Read More


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.