Emergency Medical Services Agenda 2050. How do see the future of EMS?

The EMS Agenda 2050 “Envision the Future” Straw Man document has been released to the public for comments to guide the future direction of EMS.  The document is a comprehensive and robust body of work with a wide range of topics, all of which are important to the EMS profession.

The Center for Patient Safety (CPS) was founded in 2005 and shortly thereafter began working with EMS.  Over the years we have worked to raise awareness and offer creative solutions around patient safety.

Since our work at CPS is a specialized area of healthcare we are excited to see that the Technical Expert Panel has included a section on patient safety in the Straw Man document.  The document doesn’t merely mention the importance of patient safety but includes 9 areas that focus on the topic of patient safety and developing a culture of safety.  In addition, the areas listed offer innovative and actionable steps for EMS leaders to implement for the reduction of preventable harm.

Today, we see an opportunity to create action and change in the EMS profession regarding patient safety.  Please join us in reading the Straw Man document and then comment on it to let your voice be heard.  CPS will be advocating for the steps listed in the document and welcome your insights on this valuable document-with your input we can effectively address the issues surrounding patient safety.

To learn more about EMS Agenda 2050 and read the Straw Man document use this link.


PSO Legal Update: A new focus on reporting

The Center for Patient Safety’s staff has been fielding a lot of questions about what information can be protected under the Patient Safety and Quality Improvement Act and how that relates to reporting to the PSO.  The basic rules have not changed, but there is some new focus on reporting, which is the touchstone for all the definitions in the Act and the Final Rule.  So, this explanation will start at the beginning.  

The Act defines Patient Safety Evaluation System (PSES) as “the collection, management, or analysis of information for reporting to… a patient safety organization.”  The PSES can collect, manage and analyze; it need not just gather information and report it in its “virgin” form.  Inside the PSES, information can be aggregated, sorted, evaluated or otherwise processed as part of the organization’s patient safety activities.  

The Act has a two-prong definition of Patient Safety Work Product (PSWP).  The first prong is information “assembled or developed by a provider for reporting to a patient safety organization and… reported to a patient safety organization.  AHRQ refers to this as the “reporting pathway.”  That information needs to be gathered for purposes of reporting and actually reported.  The language itself does not address non-reported material.

The second prong of the PSWP definition, though, is the source of much value for PSO participants, as it is what protects the actual work within their PSES.  The Act also defines as PSES items “which identify or constitute the deliberations or analysis of, or identify the fact of reporting pursuant to, a patient safety evaluation system.”  To meet this definition, the PSES must conduct some deliberation and analysis of information that it has acquired.  And since the purpose of the PSES is to develop reportable information, the deliberations and analysis must take place in the course of (and generate material related to) synthesizing reported material.

CPS does not believe this means that ONLY information reported to the PSO can be protected.  We do, however, recommend that our participants only try to protect information that comes into the PSES or is developed within the PSES as part of a process that leads to reports to the PSO.  Those reports can be in the form of Common Data Format reports, root cause analysis that you send to a PSO or information that is functionally reported in connection with some actual reporting.  (If you have questions about functional reporting, you should contact CPS.)  And remember, you can meet the reporting requirement by sending your PSO PSWP or non-PSWP.  So, if you need to share a part of your RCA with a regulator, you can still report it and protect the process that developed it.  The point of reporting is to share your learning with others.

CPS staff will continue to remind our participants of the importance of reporting.  We don’t know how much is enough, but we know that an absence of reporting will lead to an absence of protection.

CPS Releases PSO Report: #CultureForward

The Center for Patient Safety, a Patient Safety Organization (CPS PSO), is pleased to present this report summarizing some of the information we are learning from the collaborative participation of healthcare providers across the country.

Please note throughout this report, each contracted provider with the CPS PSO participates voluntarily. Each participating organization may elect to report different types of patient safety events, or they may elect to only submit information about the least or most severe cases, therefore, analysis of PSO data is always conducted with this understanding. Benchmarks and rates are unattainable without having a complete data set, so the information in this report is intended to offer a snapshot of the trends and findings from the thousands of events we have collected from hospitals, long-term care organizations, health systems, home health, emergency medical services, and medical offices.

We hope you find value in the information we have provided in this report. If you are not yet participating with a PSO, please contact CPS and we would be happy to help you with your selection process. All PSOs are different and it is important that you find the one that best meets your needs. As a reminder, organizations can participate with more than one PSO. We would encourage you to do so if there are beneficial offerings to your organization. Some PSOs are specific to, for example, children’s hospitals, while others may be specific to Pharmacies. CPS works across the continuum of care and is positioned to help you achieve your greatness.

I encourage you to review this report and compare the findings to patient safety concerns at your own organization. Contact me or any member of the team for information about how we can support your organization as an extension of your quality or safety department. We want you to be successful!

Download the Report

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]).

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.


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!

Let Verge Health and the Center for Patient Safety help you meet the January 1, 2017, CMS requirement with ease.


Let Verge Health and the Center for Patient Safety help you meet the January 1, 2017, CMS requirement with ease.

Join one of these webinars:
Hospital PSO 101, December 15th at 2:00pm ESTverge-1215
EMS PSO 101, December 15th at 3:30pm EST (EMS agencies can join a PSO too!)

The Center for Patient Safety will share information and answer questions on how joining a PSO can help you improve patient safety at your organization:

  • What are the benefits of joining a PSO?
  • How can a PSO support your patient safety efforts?
  • How can PSO protections apply to your organization?

Who should attend?
Healthcare professionals with a desire to improve patient safety and reduce patient risk, including professionals and leaders working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants.

Why join a PSO?

  • Protect. A PSO offers federal confidentiality and privilege protections of the Patient Safety and Quality Improvement Act of 2005 to all licensed health care providers.
  • Learn. Working with a PSO offers sharing, learning and educational opportunities.
  • Prevent. A PSO recommends proactive measures from lessons learned to assist in the prevention of future adverse events.

Who can participate with a PSO?
Any licensed provider can participate with a PSO.  CPS works with providers across the continuum of care, including hospitals, health systems, medical offices, ambulatory surgery centers, emergency medical services, nursing homes, home health and hospice, and pharmacies.

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.









It’s time for healthcare organizations to partner up with a Patient Safety Organization. Are you ready?

It’s time for healthcare organizations to partner up with a Patient Safety Organization. Are you ready?

Hospitals have an approaching deadline to sign up with a Patient Safety Organization (PSO) for the upcoming year. As a stable and experienced Patient Safety Organization, the Center for Patient Safety is poised to help you avoid costly errors in your healthcare facility.

PSOs support the collection, analysis, sharing and learning from incidents, near misses and unsafe conditions in through the use of Common Formats for uniform reporting of patient safety events.

CPS’ themes of protecting, learning and preventing also serve as three major reasons to join a Patient Safety Organization:

  • Protecting. CPS offers a way for licensed healthcare providers to receive federal confidentiality and privilege protections of the federal Patient Safety and Quality Improvement Act of 2005.
  • Learning. Working with CPS offers learning and educational opportunities.
  • Preventing. CPS can recommend proactive measures from lessons learned to assist in the prevention of future adverse events.

Click here to learn more about the Center for Patient Safety and how they can help you develop a culture that can reduce errors, increase morale and improve the bottom line.

CPS Safety Watch/Alert: Bariatric Patients

According to the latest data published by the CDC in September 2015, more than 1/3 of the adult population is considered obese.  Coupled with often other complex health conditions this growing patient population brings with it new challenges for the EMS provider.
Based on industry data and recent findings from event data being submitted to the PSO, the Center for Patient Safety is issuing a Safety Watch as these patients have been found to have an increased risk of:

  • airway related events
  • stretcher related events or other device failure-related events
  • patient handling, including lifting and safely moving the patient
  • medication mistakes

Some suggested safe practices include:

  • Maintain the appropriate equipment and training for the bariatric patient.
  • When moving a patient, ensure the appropriate number of personnel are present (at minimum 4 persons for patients weighing more than 300 pounds).
  • Communicate with the receiving or destination hospital to ensure appropriate equipment and staffing are available for the transition of care.  Consider an alternative destination or contingency plan if the primary receiving facility does not have the necessary equipment or staffing to provide the safe transition of care.
  • Discuss this patient population with your medical director for specific needs, equipment or other requirements.






Downloadable version


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.