It’s Time to Begin Your Journey to Improving Patient Safety and Quality in Healthcare. Are You Ready?

At the Center for Patient Safety (CPS), we feel strongly about culture being an integral part in the journey to improving patient safety and quality in healthcare. Improvements are not immediately achievable, but it’s never too late to begin the journey!

CPS encourages the use of survey assessments as a diagnostic tool to support and guide your patient safety culture improvement efforts. CPS can efficiently administer your culture survey, saving you valuable time and money.

CPS administers custom patient safety culture surveys for:

Click here to learn more about how CPS’s Safety Culture Survey Services support and guide patient safety and quality improvement efforts.

Ready to start your journey? You can also request a no-obligation estimate for your organization here.

CPS PSO Watch/Alert: Fall Risk

The Center for Patient Safety issues this alert regarding falls based on our data analysis.

Falls are a difficult and long-standing challenge for providers. While the majority of events report no harm, falls continue to result in severe life-changing injury or even death.  The CPS recommends you re-evaluate your fall risk program, considering the following best practices:

  • Ensure the fall risk assessment tool correlates to the daily workflow and all nurses are trained in appropriate utilization of the tool
  • Include all staff (dietary, housekeeping, maintenance personnel also) and physicians in your falls prevention program
  • Utilize a standardized communication tool to communicate the patient’s fall risk potential to the entire team
  • Make certain the preventative measure match the patient’s risk factors
  • Individualize/tailor preventative measures to meet the patient’s needs (i.e. bed alarms are not effective for all patients)
  • Include consistent patient rounding as part of your preventative measures
  • Implement a quick post-fall huddle process to quickly identify contributing factors that require a system/program change
  • Routinely/daily review medications and their effect on each patient’s fall risk potential

This alert is provided to increase awareness regarding the complex considerations required for a successful falls prevention program.



Are Critical Thinking Skills Becoming Extinct?

As an RN for nearly 30 years, I’ve seen many changes in the healthcare arena since I started as a Student Nurse Assistant in 1986. I recently had a discussion with other healthcare providers regarding the identification of patients with sepsis. The topic of young healthcare providers lacking critical thinking skills came up. This is a conversation that I’ve had with multiple healthcare providers over the past few years, but this time it just really frustrated me. The conversation brought up many potential contributing factors, such as patients entering the hospital more acute than they have been historically; shorter duration of hospital stays; and the emergence of technology.  After the conversation I began thinking that maybe today’s generation of healthcare providers is disadvantaged in that documentation is electronic and mainly checkboxes, placing a reliance on technology.  My theory is that maybe there is an association between actual writing, and learning the relationships and associations that are the foundation for critical thinking skills.

I began thinking of my own career as a Neonatal ICU nurse and remember how the first institution I worked at required an environmental assessment ….gasp…handwritten (actually EVERYTHING was handwritten, I even had a color coded pen, one color for day shift, another for evening and another for night) at the beginning of every shift. So, I had to start off my shift writing:  “Received infant in “name of warmer bed brand/isolette brand” set on “manual mode/servo mode” set at “__”. Infant on “type & brand of ventilator” settings at “list the settings” with “self-inflating bag or anesthesia bag at bedside.”  Infant attached to “brand of monitor” with heart rate alarms set at “…”, respiratory rate alarms set at “…”, B/P alarms set at “…” and O2 sat alarms set at “…”.”  Anyway, I think you get the idea.  But the point is that writing this assessment set into motion relations between what I was writing/observing and the condition of the infant.  It started the foundation for that “critical thinking process.”  I remember learning through writing my observations/assessment on a premature infant the association between hypothermia and hyperglycemia…that it usually meant the infant was stressed and we (the healthcare team) needed to be assessing possible causes. So going back to my theory of recognizing relationships/associations through writing what you’re observing had me going to Google (yes, I confess to absurd love of Google for all my questions!). What I found was a multitude of articles supporting my theory that writing notes does help your brain develop relationships and associations.  Now granted a Google search is definitely NOT scientific research of any kind, but it does provide a starting point.

That leads me to wondering how we can help the upcoming generation of healthcare providers develop these critical thinking skills. Technology is here to stay and to be honest I think it’s a good thing! But, I can see where the above mentioned factors can put up a barrier into the development of critical thinking skills.  Patients are more acute, they usually have a multitude of diagnosis, not just one.  The stay in the hospital is also shorter, which actually means that healthcare providers need to have those critical thinking skills as the opportunity to observe/assess your patient is shorter. So my question to other healthcare providers is threefold:

  • What do you think? Are critical thinking skills becoming extinct?
  • If so, what are some potential solutions to help develop critical thinking skills?
  • How can we leverage technology to assist with the development of critical thinking skills?

The U.S. FDA published safety information regarding heater-cooler devices

The U.S. Food and Drug Administration (FDA) published safety information to heighten awareness about infections associated with heater-cooler devices used during open-chest cardiac surgical procedures that utilize an extracorporeal bypass circuit. There is the potential for nontuberculous mycobacteria (NTM) organisms to grow in the water tanks of the heater-cooler device. While the water in the heater-cooler device is not intended to come into direct contact with the patient, if water within the heater-cooler tanks is contaminated with NTM, there is the potential for it to become aerosolized into the operating room and enter the sterile field (e.g., open-chest cavity and/or a sterile implant). NTM infections may cause serious illness or death. NTM infections are difficult to detect because patients infected may not develop signs and symptoms of infection for months to years after initial exposure. For more information about FDA’s understanding of the issue and recommendations to reduce risk of infection to patients, please visit: The FDA’s Web page on heater-cooler devices.

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.

CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

What the AHRQ guidance means for providers and their patients. 11

Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

New CPS report seeks to raise awareness of safety concerns in the EMS community. 16


  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

AHRQ Trigger Tool

AHRQ has published a new trigger tool that identifies harms due to hospital care among children.  The tool uses electronic or written data to retrospectively identify adverse events in pediatric patients. “This tool will help doctors and other practitioners caring for children to develop safer practices,” said AHRQ Director Andy Bindman, M.D. “A reliable trigger tool will help clinicians recognize potential safety concerns quickly from routine information collected from the medical record. Making providers aware of this information will help them avoid similar mistakes in the future.”

Tool is available here.

PSO’s as Standard Operating Procedures

Dr. Jay Reich, EMS Medical Director for the Kansas City Fire Department, presented last week at the EMS State of the Sciences Conference, also known as “The Gathering of Eagles”.   The conference is a unique, and highly respected, conference in EMS.   Each year, the conference offers opportunities to learn about the latest science and advances in EMS, including current research, data and industry innovations.   Those selected to present at the conference are EMS medical directors from the largest EMS systems in the United States.   In addition, other leading experts from around the world present relative information to advance the practice of EMS.

Dr. Reich’s presentation titled “PSOs as SOPs! Getting Patient Safety Organization Buy-In for EMS CQI” shared how participating with a PSO can protect the quality and safety work in EMS, as well as support the EMS medical director.   Since Patient Safety Organizations (PSOs) are fairly new to EMS, Reich outlined some of the benefits of PSO participation, such as, information and key examples of how Kansas City Fire Department is implementing efforts towards greater patient safety and quality improvement. His presentation focused on the ways a PSO supports the EMS shift to proactive efforts to prevent adverse events and unsafe conditions instead of reactive.

Dr. Reich’s full presentation can be found at the Gathering of Eagles website under 2015 presentations.

June 2014 AHRQ Web M&M Released

The most recent release of the AHRQ Web M&M: morbidity & mortality rounds on the web, include the following cases and commentaries:

Review these cases and the commentaries provided for reasons these events occurred and tips and resources to prevent similar situations from occurring at your healthcare location.

Fall Awareness Prevention Day Proclamation Signing

CPS attended the presentation of the Falls Awareness Prevention Day proclamation today in the Governor’s Office in Jefferson City.   Ten members of the Show-Me Falls Free Missouri Coalition were in attendance.   This year, Falls Awareness Prevention Day will be recognized on Friday, September 21, with numerous activities occurring statewide to educate our communities on actions to take to prevent falls.   For more information, visit the Show Me Falls Free Missouri website.


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.