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.


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.

CPS Safety Watch/Alert – Medication Shortages

Medication Shortages:

  • Adversely affect drug therapy
  • Can cause complications in medical procedures
  • Contribute to medication errors
  • Create frustration for providers & patients


  • Validate details of shortage & check with suppliers
  • Determine stock on hand
  • Determine purchase history & true use
  • Estimate time until shortage impacts agency & length of shortage
  • Identify alternative drug and sources


  • Communicate with staff details regarding shortage:
    • Specific drug & effective date/length of shortage
    • Alternative drugs/concentrations
    • Temporary guidelines & processes
  • Utilize teamwork to identify susceptible patient population
  • Review the 5 “R’s” of medication administration (Right medication, Right dosage, Right route, Right patient, Right time)
  • Implement 2-person medication read-back or cross-check policy



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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:

Physician Shares Near-Death Experience

Dr. Rana Awdish is a critical care physician who directs the pulmonary hypertension program at Henry Ford Hospital.  She recently shared her view of her care from “the other side of the bed” during a near-death experience, which has changed the way she will practice in the future.  This experience has led to a campaign to help all health care professionals communicate more effectively and demonstrate more empathy to their patients.  Listening to patients improves patient safety – Read more.

Addressing The Opioid Crisis

Sometimes health care providers do not recognize the ever-growing opioid problem as one they should address.  Think again!  Read Health Affair’s blog with suggested resources that providers and the community can use.  Together we can address this!

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.

Reduce Medication Errors in EMS

Nobody wants a medication error but often we don’t have a new strategy or method for prevention. Experts suggest that most errors are linked to a flaw in a system design or an unfortunate behavioral choice.  Regardless, working towards prevention requires better processes as well as improving our safety behaviors. To learn more, check out this article by Kim D. McKenna MEd, RN, EMT-P, recently posted at emsreference.com.

AHRQ July/August WebM&M Available

The most recent edition of AHRQ’s Morbidity & Morality spotlight cases are now available.   This edition includes cases covering Emergency Error, Discharge Instructions in the PACU – Who Remembers, and Anesthesia: A Weighty Issue…


National Call to Action to Improve Adverse Event Reporting – PSOs part of the solution!

The National Association for Healthcare Quality (NAHQ) Call to Action (download report), released in October 2012, calls for the elimination of preventable harm. While recognizing that a strong and just safety culture is a key element for improvement, NAHQ acknowledges healthcare providers still fear reporting of adverse events and a continued deficit due to a lack of a protective infrastructure to safeguard responsible and accurate reporting of quality and safety outcomes and concerns. Accelerating financial models based upon quality and safety outcome raise the stakes associated with quality and safety outcomes and further reinforces the need for an infrastructure that encourages accurate reporting.

The NAHQ calls for “leaders to implement protective structures to assure accountability for integrity in quality and safety evaluation and comprehensive, transparent, accurate data collection, and reporting to internal and external oversight bodies”.   Actionable items contained in the call to action include: “establish accountability for the integrity of safety systems, protect those who report concerns, report data accurately and respond to concerns with robust improvement”.  

Patient Safety Organizations (PSOs), like the Center for Patient Safety, support each actionable items – a source of learning about safety systems, providing federal-based legal and confidentiality protections for reporters, collecting detailed data using common data formats established by the Agency for Healthcare Research and Quality (AHRQ), and serving as conveners across large numbers of providers to learn, share the learning and support broad-based improvement efforts.


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.