PSO "Safe Tables" Result in Fall Prevention Interventions

The Missouri Center for Patient Safety now offers “Safe Tables” for its Patient Safety Organization (PSO) members.   What is a “Safe Table”?   It’s a members-only shared learning meeting among health care providers to network and exchange patient safety experiences and best practices in an open, uninhibited and legally protected environment.   The venue allows participants to share de-identified adverse events with other hospitals, gain input and support and learn from their own mistakes as well as the mistakes of others.   Ultimately, the end result is safer care for patients in all the participants’ hospitals.   View Fall Prevention Interventions developed at the Safe Table held in April 2012.

Protection Preserved: Court Decision is Good News for PSO Participants!

On May 29 an Illinois appellate court upheld a lower court’s decision that patient safety work product (PSWP) is privileged and not subject to discovery under the 2005 Patient Safety and Quality Improvement Act (PSQIA).  

Illinois Department of Financial and Professional Regulation (IDFPR) v. Walgreen, Company, 2012 IL App (2d) 110452, No. 2-11-0452 (May 29, 2012)


  • The IDFPR subpoenaed “all incident reports of medication error” involving certain Walgreen pharmacists.
  • Walgreens asserted these materials were submitted to its Patient Safety Organization (PSO) and therefore part of PSWP and not subject to discovery rules under the PSQIA.
  • IDFPR sued Walgreens, arguing that the documents were retained for purposes other than reporting to a PSO, and thus not protected.
  • The lower court dismissed IDFPR’s petition and declared the incident reports to be PSWP, as defined by Walgreen’s PSO policies; IDFPR appealed.

The Illinois appeals court’s decision in favor of Walgreens is based on two provisions of the PSQIA… (more…)

Is there a link between physician specialties and likelihood of malpractice claims?

A recent New England Journal of Medicine article finds physician specialties can face high risk of claims, variations in lawsuits and variations in payments. The report states that “75% of physicians in low-risk specialties and 99% of those in high-risk specialties were projected to face a [malpractice] claim,” and many will encounter their first claim before they are 45 years of age.
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5 Current Trends in Patient Safety (from ASC Review)

Article from GE Healthcare Performance Solutions on current safety trends worth reading:   PSOs, Just Culture, review of policies and procedures, use of simulation, and reduction of variance.   PSOs is listed as the #1 trend, identified as the only way health care providers can share stories and learning without fear of litigation “because big improvements in safety are about learning.”

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MOCPS Participating in Missouri EMS Conference and Expo!

The EMS PSO Project continues to expand! MOCPS is co-presenting a session at the Missouri EMS Conference and Expo on July 28th in Branson, Missouri, with Jason White of the Missouri Ambulance Association.   This presentation will focus on the history of the Missouri EMS PSO Project, where we are today, and where we hope to see it five years from now!

National PSO Program – Focus of AHRQ Podcast


Hear Dr. Bill Munier, Director of the Center for QI and Patient Safety at AHRQ, discussing the national PSO program, and its importance to improving safe care.

5 Years of Progress – 2010 – JUST RELEASED!

Pride in our work! We think it really shows in our recently published report: 5 Years of Progress-2010.

Safety improvement involves everyone who drives the delivery of health care, and many have established important partnerships with the Center.   Together, in just five years, we established the Center as a leader in PSO services, working with more than 180 providers to report medical mistakes, efficiently learn valuable information from those mistakes, and take actions aimed at prevention. (more…)

Safe Health Care – What Missouri Providers are Doing for You

As a federally designated Patient Safety Organization (PSO), MOCPS is part of a national program which will have reduced preventable adverse events by 3% within the first five years of operations of PSOs, according to estimates from the federal Department of Health and Human Services, saving $435 million in national health care costs.

Safe Health Care – What Missouri Providers are Doing for You


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.