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.


CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators


  • Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator.
  • Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to experience a lock-up condition after a defibrillation shock was delivered.  This condition is defined as a blank monitor display with LED lights on, indicating power to the device, but no response in the keypad and device functions.
  • The company is contacting customers with impacted devices to schedule the correction of their device(s), which will include an update to the firmware for a component on the System Printed Circuit Board Assembly.


  • If a device exhibits the lockup condition during patient use, the steps from the General Troubleshooting Section (page 10-18) of the LIFEPAK 15 Monitor/Defibrillator Operating Instructions should be immediately followed:
    • Press and hold ON until the LED turns off (~5 seconds) Then press ON to turn the device back on
    • If the device does not turn off, remove both batteries and disconnect the device from the power adapter, if applicable.  Then reinsert batteries and/or, reconnect the power adapter, and press ON to turn the device back on.


The #1 topic they didn’t teach you in Paramedic School: Culture

I have been working with the Center for Patient Safety (CPS) for about four months, and I’m learning something new every day.  As a Paramedic, patient safety has always been a high priority, but I didn’t know how an organization’s culture could impact the delivery of care.

Much of what we do at CPS is to educate, inform and help others make the connection between culture and safety.  While that might sound simple, it’s a rather complicated task.  Also, it’s about finding leaders and providers that are willing to listen and learn about these concepts that aren’t taught in Paramedic school.

Culture is comprised of many things including the collective beliefs, attitudes, perceptions, and values of the employees and the entire organization. How would you describe your organization’s culture? Did you know that you can measure it?

The EMS Safety Culture Assessment provided by CPS offers an organization the tools to understand their strengths and opportunities when it comes to their safety culture.  Many use it as a tool before implementation of just culture or as a baseline measurement of the values within their organization and then come back a year later and re-measure to see how their work has improved the safety culture.

The Safety Culture Assessment can also help with local or regional quality improvement projects and initiatives as it measures areas such as patient handoffs and communications between healthcare providers. These are just a few reasons why measuring your culture should be something that is not only accepted by EMS but expected in EMS just as it is in other healthcare settings.

Years ago I worked as a flight Paramedic and the safety culture in an air-based service seemed to be more advanced since it was linked to aviation. It was acceptable to turn down a flight and have a safe time-out due to severe exhaustion or if something didn’t seem right. As a ground paramedic, a safety time-out didn’t exist and many had never heard of it. Today, many years later, safety precautions like time-outs, are more common and practiced within a growing number of ground organizations.

One of the interesting things I get to do in my new position is listen to how leaders and providers describe their safety culture.  However, just like the safety time-out, many have never thought about it or can’t describe it.

One agency recently completed the EMS Safety Culture Assessment and learned of staff concerns regarding a change from 24-hour shifts to 48-hour shifts and how that change could impact patient and provider safety. As a result, the ground service implemented a time-out policy that addresses exhaustion, a pro-active approach to building a safe culture.

Do you have a safe organization where employees come to you with concerns about an unsafe situation or when a mistake occurs? Alternatively, are you the Chief that believes near misses and mistakes do not happen within your organization? How do you truly know the thoughts and feelings of the employees within your organization if you haven’t assessed the culture or given them the opportunity to speak up without the fear of repercussions from their colleagues and administration?

Our mission at the Center for Patient Safety is: Reducing preventable harm, but what does that mean and how do you accomplish that? The EMS Safety Culture Assessment is the first step in recognizing and learning about the culture component of your organization.

The EMS Safety Culture Assessment provided by CPS gives employees a voice that is trusted and de-identified so they can speak up without fear of retribution from colleagues or punishment from administration. The assessment also helps administration recognize the need to fulfill a safe practice and utilize the results to make positive changes within their organization.

Shouldn’t all first responders feel safe within the environment they call their second home?

Please contact me so we can start your EMS safety journey today! Your employees and your community are counting on you!

Shelby Cox

Healthcare Forward Report: Patient and Provider Safety

The Center for Patient Safety (CPS) is excited about our new report being released this week: Healthcare Forward. While CPS began in 2005 with a focus on patient safety efforts in hospitals, our services have since expanded across the continuum of care and the new report highlights safety issues observed, not just in hospitals, but in all areas of healthcare. CPS works tirelessly to reduce preventable harm through services and programs designed to collect information around adverse events, near misses and unsafe conditions. CPS reviews contributing factors with the end goal of helping organizations provide safer, high quality care for their patients. It is based on the review of this information, combined with our expertise in the field and ongoing research in the industry, that the information in this campaign is prepared.

Healthcare is aiming for the goal of becoming a high reliability organization. The challenge for healthcare is meeting specific outcome measurements for reimbursement while continually evaluating processes. However, if healthcare is to continually provide high quality, safe, patient care across the continuum of care, the challenge must be met! The process of driving healthcare forward as a high reliability organization or business encompasses five steps. First; to be sensitive to operations (understand processes). Second; to be reluctant to accept the first explanation for an adverse events. Third; to have a preoccupation with failures. Fourth; to defer to expertise and lastly to show resilience.

Another ideal healthcare need is to hardwire the idea that patient safety isn’t a concept that should be boxed into hospital or inpatient care.  Rather, patient safety should be a priority across the continuum. Patient safety should start with the patient’s home and their own health literacy and be an integrated value of all healthcare providers from hospitals, to medical offices, long term care facilities, home care providers and EMS.

Support and care for healthcare providers is another foundational component that many healthcare organizations have been missing for many years. Healthcare is looking at a current shortage of both nurses and physicians.  Burnout is very real.  To keep skilled professionals in healthcare organizations need to have processes and programs in place to support a provider if an error occurs that harms a patient.

Organizations also need to ensure that appropriate support and systems are in place for healthcare providers if/when they are subjected to violence in the workplace. Being the target of verbal/physical abuse or harassment should not be considered “part of the job”.

This new CPS campaign looks at how patient safety is integrated across the continuum of care.  It focuses on the components that can move Healthcare Forward, principles such as communication, organizational culture, and leadership.  It doesn’t matter what area of healthcare a provider works, all three components are required to move the needle in regards to patient safety. First, leaders set the example through their actions. Second, communication should be open, shared and verified; and lastly, a strong patient safety culture encourages open discussion regarding adverse events, near misses and unsafe conditions.

The new report highlights five different patient care topics and these principles play into the different topics.  These topics include health literacy, opioid safety, medication reconciliation, respiratory compromise, and transition of care.  Each topic includes case scenarios from different healthcare arenas and offers questions for leaders and employees of organizations to ask themselves in regards to their policies and processes.  The report also contains two areas of support for healthcare providers: second victims and violence against healthcare workers. These topics also contain scenarios, but more importantly the questions posed provide a starting point for healthcare organizations to begin putting into place programs to support and retain their staff.

Patient safety isn’t isolated to inpatient care, it’s a fundamental concept of patient care and a right of every single patient. Safety is also a core component for healthcare providers.  To retain qualified staff and attract new staff, organizations need to have the systems and processes in place that also support their employees. Our hope is that this report will help bring not only the fundamentals of patient safety to the forefront in all healthcare arenas, but especially the concept of a strong patient safety culture.

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.


EMS Patient Safety Coordinator, Shelby Cox

The Center for Patient Safety is pleased to announce the recent hiring of Shelby Cox to the new EMS Patient Safety Coordinator position.  Shelby brings many years of EMS experience and a strong passion for improving patient care.  Please join us in welcoming Shelby to the CPS team.


As a Nationally Registered Paramedic with more than 20 years invested in emergency medical services, Shelby has served in varying capacities including  ground ambulance transport, air medical services, hospital liaison, EMS education and hospital outreach management. She has a passion for helping people and has always been drawn to making a difference.  Today she is inspired to help EMS colleagues reduce preventable harm.  She describes this new role as part of an amazing journey where she can use her experience on a larger scale.

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


Download Here


Approach to Safety

The Center for Patient Safety agrees with Dr. Tejal Gandhi’s advocacy for “a total systems approach to safety” — where safety is at the core of health care delivery across the continuum and a primary focus of any new initiative. Creating such approaches will require innovative thinking and contributions from all stakeholders.”  Dr. Gandhi’s blog can be followed here.  The Center For Patient Safety can help you advance your patient safety journey.


CPS Safety Watch/Alert – Respiratory Compromise


Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Respiratory Compromise creates problems that are often serious and potentially life-threatening, but they are almost always preventable with the proper tools and approach.  Appropriate patient monitoring and therapeutic strategies are necessary for early recognition, intervention and treatment.

Common themes include:

  • Lack of appropriate monitoring and early identification of respiratory compromise
  • Distractions, complacency or failure to identify high risk patients at transitions of care
  • Not anticipating respiratory complications or lack of situation awareness
  • Complications and risks from procedural sedation


  • Understand the pathophysiology and clinical factors of respiratory compromise
  • Early identification of patients at risk
  • Appropriate and timely patient monitoring
  • Appropriate and prompt interventions and treatment


*Respiratory Compromise Institute

Thanks to Dr. Brian Froelke, CPS



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.