CPS Safety Watch/Alert – Violence Against Healthcare Workers

SAFETY ALERT: Violence Against Health Care Workers


  • Verbal Threats
  • Hitting
  • Biting
  • Scratching
  • Kicking
  • Stalking
  • Harassment


  • Review policies and education of staff pertaining to the recognition and de-escalation of hostile and aggressive behavior by patients.
  • Evaluate the need for security personnel and mental health professionals to assist with identification and de-escalation of aggressive behavior.
  • Assess physical work environment to limit/eliminate the possibility of staff working in isolation without escape route in the possibility a patient becomes physically aggressive.


  • Ask your staff if they feel comfortable reporting aggressive behavior
  • Encourage staff to use teamwork strategies such as ensuring a second staff member is readily available to assist with procedures where patients have increased risk of becoming aggressive
  • Leadership should evaluate the culture and consider implementing a support system for staff members who feel threatened/intimidated by patients


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Patient Safety Awareness Week is March 11-17, 2018

Patient Safety Awareness Week (PSAW), an initiative from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement, is designed to raise patient safety awareness among healthcare providers and consumers. This year, PSAW is March 11-17. It’s a great time to celebrate successes and re-focus on patient safety opportunities in your organization. The Center encourages providers and consumers to obtain information about patient safety issues. Below are highlights of Patient Safety Awareness Week activities.

Take advantage of the following resources and conferences to help launch a successful campaign! The Center’s highly anticipated Patient Safety Toolkit will be available for download by CPS Subscribers.

Join us on social media and check out these patient safety resources and tips we’re sharing during #PSAW2018!

Patient Safety Forum, March 14, 2018

Everyday across the country, healthcare is provided in many clinical settings and environments.  Likewise, the healthcare landscape is complicated as it evolves at an ever-quickening pace with new specialties, titles and tools.  Coupled with the growing demands placed on clinicians and healthcare leaders, how do we ensure the safety of our patients?  Join us for this collaborative opportunity to learn with other providers across the continuum of care how patient safety can be improved.
Added Bonus! All attendees of the forum will become a Subscriber to CPS’s online resource center, which provides toolkits, special previews to upcoming events, and a community forum. Find out more about becoming a subscriber!

Learn more about the Forum

Second Victim Experience, March 19, 2018

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.

Added Bonus! All attendees of the workshop will become a Subscriber to CPS’s online resource center, which provides toolkits, special previews to upcoming events, and a community forum. Find out more about becoming a subscriber!

Learn more about the Second Victim Workshop

The CPS Patient Safety Improvement Approach

The Center for Patient Safety believes every patient safety improvement journey includes an evaluation of your current culture. It’s important to use meaningful data to understand how staff perceive the organization’s approach to patient care. Our bundled approach gives you peace of mind that you’re working with the patient safety experts – and we want YOU to be successful!

Step 1: CPS administers a survey to your staff and provides a detailed interpretation of your results.
Step 2: We work closely with you to develop your action plans and next steps.
Step 3: Our work continues with you over the next six months to a year to provide education and training, workshops, resources and tools. We support you in reaching your goals!
Learn more about the CPS Patient Safety Approach through Culture Change

CPS Safety Watch/Alert: Elopement


  • Nursing, Medical & other Clinical Leaders
  • Clinical Educators
  • Patient Safety/Quality Improvement Leaders
  • Legal/Risk Management
  • And Leaders in:
    • Hospitals
    • EMS
    • LTC
    • Home Care

Safety Watch v4-2 Elopement

Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated with these scenarios include increased risk of:

  • Adverse events
  • Misdiagnosis
  • Mental health exacerbation
  • Diversion which can lead to dangerous delays of care


  • Review/establish an elopement policy
  • Review triage policy/process
  • Identify those at risk for elopement (such as those suffering with psychosis, dementia, drug or alcohol-related conditions)
  • Perform a gap analysis to address issues such as opportunities to reduce risk, assessing staffing, etc.


  • Open Communication: Interview staff to see if they have concerns regarding patient elopement
  • Teamwork: Develop a communication tool that will inform all ED staff of a high risk elopement patient.
  • Share: Openly share peer-reviewed best practices from the literature and processes that have been implemented at your facility or other facilities.



  • Share this watch with the target audience
  • Promote daily safety briefings
  • Continue to share incidents, near misses and unsafe conditions with the Center for Patient Safety

QAPI: 10 Steps to Improvement

Long-term care providers face new expectations for their safety and  quality work in the form of CMS’ QAPI standards. Yet a simple and methodical approach can help LTC providers create a program that meets CMS’ expectations and improves care for residents. Primaris has published a great list of suggestions (“10 Simple and Effective QAPI Planning Tips”) for those who want to strengthen their program; it is available here.

And remember:  CPS has tools and programs that can be integrated into this planning for an even stronger program. The AHRQ Survey of Safety Culture helps LTC organizations identify areas ripe for QAPI improvement and helps measure baseline and post-intervention safety culture to demonstrate improvement.  CPS also offers programs to help with the improvements that might grow out of the survey.  And organizations that participate with CPS’ Patient Safety Organization (PSO) can share their learning and protect it from discovery at the same time.

For  information about the AHRQ Safety Culture Survey, contact Alex Christgen ([email protected]).

For  information about  the Center for Patient Safety PSO, contact KathyWire ([email protected]).

Nursing Home Week Spotlight: Kathy Wire

The Center for Patient Safety is proud of our diverse team and is especially proud of our Patient Safety Specialist, Kathryn Wire, JD, MBA, CPHRM, CPPS. Having spent much of her time in nursing homes, hospitals and health systems throughout her career, she now enters her tenth year with the Center in a supporting role. She is a valuable resource to all of our participating organizations. We recently sat down with Kathy and asked her a few questions…

Q: What first interested you in healthcare?
I stumbled into healthcare when I began defending hospitals in my first job at a law firm.  Within a few years, I moved into the field full-time, working for a hospital.

Q: Why is patient safety important to you?
I have always worked in patient safety in some form.  Initially, it was a way of preventing exposure in lawsuits.  But it became clear that our goal had to be good care, not just avoiding legal losses.  Then, there was not a “patient safety” function in the organizational structure, but it was the end result of doing work well.

Q: What do you miss most about working on the front lines (or in a care setting)?
I miss the contact with the people we work for and the fast pace of work.

Q: What do you enjoy most about working at the Center for Patient Safety?
CPS has a great bunch of people who all just want to make care better. 

Q: Based on your experience in the healthcare provider setting, and your experience at the Center, what is your message to other [nurses/LTC/EMS/Hospitals]?We have to look at safety issues with an attitude of abundance:  “We can make this better.”  The rest is details.

Q: What is your greatest achievement around patient safety (either in a previous job or current job)?
Early in my career, I worked very hard to move the focus from lawsuit losses to performance improvement and managing communication and conflict with our patients and families.  It is both satisfying and frustrating to see that so much of the healthcare industry is still struggling to make that transition 20 years later.  But every bit of progress helps.

Q: What was the last book you read?
The Girl on the Train

Q: Who do you admire?
The women on the Supreme Court.

Q: Anything else you’d like to share – interesting tidbits about where you’ve lived, where you’ve worked, about spouse, children or grandchildren, etc?
I was raised in a family that stressed generosity with time, treasure and talent.  I hope I can continue that theme and I am proud of the fact that my kids and bonus (in-law) kids all work in helping professions and have followed a similar path. 



They say the only constant thing in life is change, and it’s no different at the Center for Patient Safety (CPS). Since the first IOM report was released in 1999, patient safety concerns have been in the spotlight, and the CPS was created to address the issues in that report confronting healthcare. Since we opened our doors in 2005, we have supported thousands of organizations across the country with their patient safety programs; and now, years later, we continue our mission. I assumed the position of Executive Director of CPS in July of this year, and it has been an incredible journey. What appealed to me most about the opportunity to lead CPS is the ability to energize, engage, and inspire health care providers across the country, and throughout the world, to reduce avoidable patient harm. Our team has been hard at work this year, developing some of the most innovative concepts ever to reach the front line staff, and I can’t wait to share them with you. Our team has so much to offer the healthcare community. The energy that comes from the clients and providers we work with through CPS daily is absolutely amazing! Each provider is dedicated to promoting patient safety in their organization. They are driven by compassion and a selfless desire to improve care. They are an inspiration to our team and to their communities.

I invite you to be an active participant with the Center for Patient Safety in a manner that best fits your abilities:

• Host a patient safety boot camp in your region
• Join us for any of our ongoing educational webinars
• Share a success story and best practice in our newsletter
• Be a part of our PSO to share and earn protections
• Be a sponsor for an organization or program
• Ask us about our culture improvement opportunities
Each person that contacts us has their own barriers, concerns, and issues that keep them up at night. Many of these issues are some of the same things our team dealt with during their many years of experience. Our team knows how you feel, and we know how to help. This will certainly be an exciting time as CPS continues to grow and improve culture and patient
safety across the country. We strive for excellence in our delivery of services, which is achievable through our revised mission of providing creative culture solutions to improve patient safety. Join our mission today by following us on LinkedIn, Facebook or Twitter, or contact our office to find out how you can engage with CPS today!

FREE WEBINAR – Safety Culture Assessment for LTC

Culture impacts everything we do. And it’s no different in health care organizations. The strongest cultures support employee engagement, promote open communication and the sharing of mistakes to foster improvement.

Learn about how the Center’s administrative survey can save you time and money and why measuring your culture is so important to improve patient safety.

Webinar – Tue, Nov 1, 2016 1:00 PM – 2:00 PM CDT

Register Here!

Trigger Tools

Trigger tools help healthcare providers identify possible safety events and concerns by looking at conditions that often accompany those safety events.  For example, by examining the administration of rescue drugs (the trigger), a provider may identify safety risk to residents/patients from poor glycemic control.  While the proper use of trigger tools can be time consuming, they can shine light on many otherwise hidden concerns.  The Institute for Healthcare Improvement (IHI) has developed a trigger tool for skilled nursing facilities, which is available at no charge here.  IHI is also offering a virtual course starting August 10 for those interested in learning more about the tool and how it can support safety and quality learning.  There is a fee.  More information about the course and registration is available here.

Pill Organizers:  A Yellow Flag for Caution

McKnight’s Senior Living magazine shared some counter-intuitive but important research recently.  The article is available here. The researchers found that individuals had more adverse events from medication after they switched to a pill organizer in home or assisted living settings.  Why?  Two things happened when they took their medication less reliably. First, they were less likely to have side effects because they were not getting the full dose daily.  The researchers also believed that unreliable intake of their medication resulted in insufficient medical benefit, so their providers increased the doses.  Once they began to take the medication regularly, the ordered doses were too high.

This study has relevance for assisted living providers, home health agencies and also for the professionals prescribing the medication. In addition to monitoring the patient after the change, they can try to find out how often prescriptions have been filled in the past—an indicator of the actual rate of consumption of the medication.


The Missouri DHSS LTC Information Update this week included some links to videos with helpful suggestions for handoff and care communication.

Here they are:

SBAR Video

Checkback Video

I PASS the BATON Video


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.