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.

A Second Look at the Report on Medical Errors from IHI

While it is very difficult to have an “accurate” statistic for the rate of harm, the definition could and should be much broader, which would make the numbers even higher.  No matter the number, we need to focus on improving processes to reduce all harm! Read more.

Focusing on Both Deaths and Harm from Medical Errors

Focusing on Both Deaths and Harm from Medical Errors

In his latest post to the “Line of Sight” blog, IHI President and CEO, Derek Feeley, reflects on the controversy and criticism surrounding a recent British Medical Journal article, which asserts that medical errors would rank as the third leading cause of death in the US if government calculations included these errors. Feeley welcomes the debate on how best to calculate the number of lives lost as a result of such errors, and he proposes that focusing on preventable deaths is necessary but not sufficient. It’s equally important, he says, to better understand and address the myriad types of preventable harm patients suffer from medical errors.

Medical errors are third leading cause of death in US

A recent article from BMJ states medical errors are the third leading cause of death in the US after heart disease and cancer. The article follows the 1999 IOM report which made the first attempt to determine preventable harm in healthcare. The IOM report estimated a staggering 44,000 to 98,000 patient deaths each year due to medical errors.  In 2013, the IOM’s reported numbers were determined to be grossly underestimated based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per year as result of medical errors.

The article includes the following call to action:

  1. make errors more visible when they occur so their effects can be intercepted
  2. have remedies at hand to rescue patients
  3. make errors less frequent by following principles that take human limitations into account

The article’s Call to Action aligns with the Center for Patient Safety’s (CPS) program objectives and mission. Reducing errors in healthcare is achievable with open communication in a positive culture that supports learning from mistakes in a safe environment, but not just within the walls of a single organization. Organizations and healthcare providers must learn and share with one another, across the continuum of care.

Although the article specifically references medical errors in the inpatient hospital setting, CPS’ recently released annual report suggests medical errors resulting in patient deaths in LTC, home care, ASCs, medical offices and EMS settings may be just as prevalent.

CPS supports patient safety efforts through the provision of programs aimed at improving organizational culture, increasing awareness of medical errors, and providing an environment that supports safe discussion of mistakes.  Through Protecting, Learning, and Preventing, CPS is working with organizations and healthcare providers across the country to improve patient safety every day.

Contact us to join the healthcare movement to safer care.

Reducing the Risk of Using Medication Abbreviations – A reminder from ECRI

In the world of risk mitigation, it’s not often that there’s a straightforward solution. So, when there is, it’s worth some serious consideration. In the case of error-prone medication dosage abbreviations, it’s as easy as this: don’t use them (available to the public for a limited time).  Use of medication dosage abbreviations is a long standing, well known patient safety risk, but errors continue to occur. Some solutions have been shared by the ISMP (list of error-prone, abbreviations symbols and dose designations), NCCMERP, USP and TJC (Do Not Use List) as well as ECRI. One solution is to effectively use CPOE to avoid use of risky abbreviations and other prevention strategies such as avoiding print materials with abbreviations, use of reminder cards, laminates, posters, etc.

Ketamine Use Fatal Error, Lessons Learned

The unfortunate death of a 55 year old man at the University of Vermont Medical Center resulting from a five-fold overdose of Ketamine leads to many lessons learned for safe medication policies, medication administration and timeliness of action plan implementation for hospitals and EMS:

Lesson #1 – Consider the danger of using multi-dose vs. single-dose vials as an organization-wide policy. Most importantly due to the risk inherent in the use of multi-vials but also to reduce wastage of medication that may be in short supply. In this case, Ketamine was available in multi-dose vials and five doses were drawn up instead of only the one ordered by the physician.

Lesson #2 –  Medication administration policies should be monitored and enforced, particularly if multi-dose vials are in use.  In this case, the hospital policy was to only draw up the medication ordered and intended for administration, yet common practice by nursing, particularly in emergent situations, was to draw up multiple doses at one time in order to be ready for subsequent orders.

Lesson #3 – The importance of timely evaluation of the cause of such events and implementing action plans. In this case, although there is some discrepancy among those involved, there was evidence that the five-dose vials had not yet been removed from the medication boxes up to 49 days following the fatal event.

Read full story.

CPS Safety Watch/Alert: Prevent Fatal Medication Errors

The National Alert Network recently issued an alert based on a fatal medication error where a nurse confused fluid drams with mL.  While the healthcare system bases most of its medication on the metric system, many measuring cups utilized for liquid medication not only still have drams listed, but also ounces listed.  Harm could be prevented by the utilization of dosage cups that only measure liquids in the metric system.  Read the full alert.

PSOs and Others Chime in on ACA Delayed Rule for PSO Participation

The Center for Patient Safety and others discuss concerns and benefits of the delay in the PSO participation rule requirement of the Affordable Care Act. While the delay allows additional consideration on how to implement the rule, are current Medicare requirements sufficient to move patient safety improvement forward? Will the delay stifle the expanded sharing, learning and prevention of medical errors possible through PSOs?   Read full February 4 Modern Healthcare article.

Seven components of a friendly medical error reporting environment

Henry Ford Health System shares seven components of a friendly medical error reporting environment:   leadership support, appropriate infrastructure, anonymous reporting, error disclosure to patients and families, communication, just culture, and continual improvement of its patient safety culture.   Their successes were recognized in 2011 when they received the Malcolm Baldrige National Quality Award and the John M. Eisenberg Patient Safety and Quality Award.   Read more.

Are you at risk for wrong site surgery?

Think a wrong site surgery can’t happen at your hospital or surgicenter?   Every surgery or invasive procedure is at risk!   The Joint Commission recently shared 5 tips to reduce the chances:

1.   Evaluate your entire operative process to identify areas of risk

2.   Standardize your scheduling process; do not allow the use of abbreviations

3.   Assign specific active roles for the time out; everyone must be consciously involved

4.   Reference the marked site during the time out; allow only permanent markers so the marking is visible

5.   Don’t rush the time out

Learn more:   http://www.beckersasc.com/asc-quality-infection-control/5-time-out-tips-for-safe-surgery.html


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.