Patient Safety Resources

Are you frustrated because others in your organization don’t seem to have the same passion or urgency to improve patient safety?  Limited resources and increasing financial pressures are driving the focus on patient safety down on the list of priorities.  It’s difficult to build a business case to support the importance of constantly improving patient safety.  Now there’s help!  The Institute for Healthcare Improvement and National Patient Safety Foundation recently published a resource to assist you – and it’s free!  Remember that improving patient safety is a journey, not an initiative.  Never give up!

CPS Safety Culture Assessment

“I am very impressed with the reports. I know my leadership team will be thrilled to have the individual reports by their division. This
has been a very positive experience for me.”

“We love the Center’s patient safety culture survey feedback reports. The department level reports give a level of granularity we
were lacking with previous surveys.”

The Center focuses heavily on culture to support patient safety improvement. A punitive environment discourages open communication of events and near misses, creating a barrier to learning about the mistakes that are occurring.

The Center has been administering the AHRQ Surveys on Patient Safety (SOPS) since 2011. Since then, we have administered hundreds of thousands of surveys and provided survey support, feedback reports, and consultation to hundreds of organizations.

A select group of 42 hospitals were selected from the 2016 database. These organizations were selected based on their activity level and extended use of the Center’s resources and services for PSO participation, webinar attendance, resource usage, and consulting. An analysis of their patient safety culture scores are compared to the national compare database from AHRQ. More than 14,000 surveys were analyzed.

  • 7 dimensions were equal to or higher than the 50th AHRQ Percentile
  • “Nonpunitive Response to Error” ranked in the 75th AHRQ Percentile
  • 23 questions were equal to or higher than the 50th AHRQ Percentile
  • “We are actively doing things to improve patient safety” ranked in the 90th AHRQ Percentile

The top strengths for these organizations align with the top strengths from the 2016 AHRQ Hospital Compare Database:

However, the areas with potential for improvement, or the lowest scoring dimensions, indicate variation in two of the composite scores:

The Center has had a long history with a focus on creating a nonpunitive environment. The dimension includes the question “Staff worry that mistakes they make are kept in their personnel file.” The higher score for the composite “Nonpunitive Response to Error” is statistically significant (>5%). Compared to the national average, the organizations in our select group are in the 75th percentile nationally.  While most of the respondent emographics for the hospitals included in the Center’s summary align with the AHRQ Compare Database, it is worth noting:

  • 15% of staff indicated they report 11-20 event reports per year; 29% indicated they report 3-5 events per year (statistically significant variation from AHRQ National Compare Database)
  • Higher numbers of reports suggest an environment that supports open communication without a fear of retribution or punishment.

Additional notes:

  • 85% of respondents had direct patient care
  • 41% of staff worked 1-5 years in the current work area
  • 36% of staff worked 1-5 years in the current hospital; 13% worked 21 years or more in the current hospital
  • 44% of staff indicated they were a Registered Nurse

Click here to download the full data report.

Interested in receiving reports like this for your organization’s departments or locations? Request a no obligation price estimate with a summary of the Center’s survey administration services.

Nursing Home Week Spotlight: Kathy Wire

The Center for Patient Safety is proud of our diverse team and is especially proud of our Patient Safety Specialist, Kathryn Wire, JD, MBA, CPHRM, CPPS. Having spent much of her time in nursing homes, hospitals and health systems throughout her career, she now enters her tenth year with the Center in a supporting role. She is a valuable resource to all of our participating organizations. We recently sat down with Kathy and asked her a few questions…

Q: What first interested you in healthcare?
I stumbled into healthcare when I began defending hospitals in my first job at a law firm.  Within a few years, I moved into the field full-time, working for a hospital.

Q: Why is patient safety important to you?
I have always worked in patient safety in some form.  Initially, it was a way of preventing exposure in lawsuits.  But it became clear that our goal had to be good care, not just avoiding legal losses.  Then, there was not a “patient safety” function in the organizational structure, but it was the end result of doing work well.

Q: What do you miss most about working on the front lines (or in a care setting)?
I miss the contact with the people we work for and the fast pace of work.

Q: What do you enjoy most about working at the Center for Patient Safety?
CPS has a great bunch of people who all just want to make care better. 

Q: Based on your experience in the healthcare provider setting, and your experience at the Center, what is your message to other [nurses/LTC/EMS/Hospitals]?We have to look at safety issues with an attitude of abundance:  “We can make this better.”  The rest is details.

Q: What is your greatest achievement around patient safety (either in a previous job or current job)?
Early in my career, I worked very hard to move the focus from lawsuit losses to performance improvement and managing communication and conflict with our patients and families.  It is both satisfying and frustrating to see that so much of the healthcare industry is still struggling to make that transition 20 years later.  But every bit of progress helps.

Q: What was the last book you read?
The Girl on the Train

Q: Who do you admire?
The women on the Supreme Court.

Q: Anything else you’d like to share – interesting tidbits about where you’ve lived, where you’ve worked, about spouse, children or grandchildren, etc?
I was raised in a family that stressed generosity with time, treasure and talent.  I hope I can continue that theme and I am proud of the fact that my kids and bonus (in-law) kids all work in helping professions and have followed a similar path. 


Hospital Week Spotlight: Eunice Halverson

The Center for Patient Safety is proud of our diverse team and is especially proud of our Patient Safety Specialist, Eunice Halverson, MA, CPPS. Having spent much of her time in hospitals and health systems throughout her career, she now enters her sixth year with the Center. She is a valuable resource to all of our participating organizations. We recently sat down with Eunice and asked her a few questions…

Q: What first interested you in healthcare?
I landed in healthcare by chance, I guess.  I needed a job when we moved to St. Louis from Minnesota as my husband was in school.  I was offered a position at St. Mary’s Health Center in St. Louis and I’ve been in healthcare ever since.  I had never worked in healthcare and I loved it.

Q: Why is patient safety important to you?
I’m not a nurse, but I love that we can make a difference to patient outcomes without being a direct healthcare provider.  I was a risk manager for many years, so I know how many errors occur and I also know that improving processes directly impacts the likelihood of errors occurring.

Q: What do you miss most about working on the front lines (or in a care setting)?
I loved working in the hospital with all the front line providers.  They have such a passion for their patients.  We had a mutual respect for each other, always working to provide the best care for every patient.  I’m still friends with many of them.

Q: What do you enjoy most about working at the Center for Patient Safety?
I love working with providers across the continuum of care.  Prior to coming to the Center, I had only worked on the acute care side, both in the hospital and at the system office.  I have learned so much about the EMS profession, and I find them very eager to learn how to improve patient safety.  CPS has a great team of patient safety professionals who all believe in the Center’s mission to be a leader in providing creative solutions and resources to improve patient safety.

Q: Based on your experience in the healthcare provider setting, and your experience at the Center, what is your message to other Hospital Professionals or Healthcare Professionals?
Don’t ever give up improving your delivery of care for patients.  Treat each one as if he or she was your loved one, always providing compassionate, safe care.

Q: What is your greatest achievement around patient safety (either in a previous job or current job)?
Wow – I’ve been privileged to achieve so many things in my career.  One of the highlights was assisting SSM Health become the first healthcare organization in the nation to receive the Malcolm Baldrige Quality Award, which included providing safe care.  I also loved working with a team to develop and deploy the “Always Safe” program across the SSM system so that every employee, physician, patient and family member knew we were focusing on providing safe care.  Recently it’s been my privilege to lead development of the Center’s EMS Patient Safety Bootcamp which we debuted in Ft. Myers, FL early in March.  Improving patient safety is so much fun!

Q: What was the last book you read?
The Berenstain Bear’s Big Honey Hunt – I love reading to my grandkids!

Q: Who do you admire?
Sr. Mary Jean Ryan, past CEO of SSM Health, had a life-changing impact on my profession as well as my personal life.  She taught me that we can always improve, no matter what.  It is now the way I think:  how can I improve that process?

CPS Partners with Verge Health to Improve Patient Safety

Verge Manages Technology while CPS Provides Consultancy Services

On the heels of Patient Safety Awareness Week, Verge Health, a leader in healthcare risk management, has partnered with the Center for Patient Safety (CPS), a non-profit organization envisioning a healthcare environment safe for all patients and healthcare providers, in all processes all the time.

“The shift to value-based care, and the vast expansion of data sharing among and between health systems, presents both risk and opportunity,” says Mark Crockett, chief executive officer of Verge Health. “We are delighted to solidify our working relationship with CPS to help improve safety by leveraging technology to help protect patients.”

Under terms of the agreement, the two companies will partner to promote products, services, and events to their respective client bases promoting the shared vision of protecting patients and margins. The agreement formalizes a long-time relationship where Verge powers the CPS PSO, and CPS offers PSO services, consultation and education around patient safety culture.

“From conducting patient safety assessments to helping hospitals and other health care organizations improve patient safety, we generate a significant amount of data that must be kept secure while being accessible,” says Alex Christgen, Executive Director for the Center for Patient Safety. “We’ve been working with [Verge] for several years to support our Patient Safety Organization, and believe our patient safety vision fits well with the IT platforms that Verge provides.”

About Verge Health
Founded in 2001, Verge Health is a risk management software company. Verge Health’s software solutions enable healthcare organizations to proactively protect and defend patients, caregivers, and frontline staff, against errors, adverse events, and policy violations. With over 900 facilities and 500,000 active users, the company’s Converge Platform provides hospital organizations with a cross-functional, proactive surveillance tool enabling optimal quality and safety results. For more information, please visit

About Center for Patient Safety
The Center for Patient Safety, is a private, not-for-profit corporation dedicated to fostering change throughout the nation’s health care delivery systems and across the continuum of care. It provides patient safety services to more than 1000 health care facilities across the nation since its inception 12 years ago, which was in response to recommendations from the Missouri Governor’s Commission for Patient Safety. For more information, go to

Florida Supreme Court’s opinion in Charles vs. Southern Baptist

A note to CPS’ participants and friends:

The Florida Supreme Court has adopted a restrictive interpretation of the PSQIA as it relates to Florida’s risk management and discovery laws.   Charles vs. Southern Baptist analyzes the relationship between the Patient Safety and Quality Improvement Act (the Act) and Florida laws that govern the development and protection of patient safety and quality material.  The Court’s opinion is available here.

Providers in Florida need to get local legal advice about the extent of the state law impact on their safety and quality work, as this is the first step in applying Charles.   Though the decision has no direct impact in other jurisdiction, it will be part of the ongoing discussion about PSO protections, so it is important to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.   The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP.


The Court held that patient safety work and the related reports, when required by state law, could not be PSWP, using the same analysis put forth by AHRQ in its Guidance last year. (AHRQ Guidance document available here.) Because the Charles information was collected or maintained for a purpose other than submission to a PSO or for dual purposes, the Court held it is excluded from the definition of PSWP contained in the PSQIA and the final rule.

This finding (that the requested information was not protected PSWP) is important when examining the next issue, whether the PSQIA pre-empts Florida Amendment 7. That provision eliminates any protection for “any records made or received in the course of business by a health care facility or provider relating to any adverse medical incident.”  This discussion won’t delve into the detailed interaction of the PSQIA definitions and Amendment 7, though the relationship is complicated.  The important thing for PSOs and their participants in other states is the Florida Court’s somewhat gratuitous finding that the PSQIA could not supersede or pre-empt Amendment 7.

CPS doesn’t recommend that its PSO participants assume that Amendment 7 has pre-empted the PSQIA. There are several reasons why PSO participants should not view this as established doctrine (or in non-legal parlance, a “done deal”):

  • The Court’s pre-emption finding may well be dicta–an opinion stated by a court that is not necessary for its decision.  Dicta can be informative, but carries little true weight as precedent.  Viewed narrowly, this is just the Florida Supreme Court stating its opinion where it doesn’t really matter.
  • The Florida finding directly contravenes language in the PSQIA (Section 922): ‘‘(a) PRIVILEGE.—Notwithstanding any other provision of Federal, State, or local law, and subject to subsection (c), patient safety work product shall be privileged.”  This sets up a potential US Supreme Court appeal.  The US Supreme Court could either (1) accept the case and decide the pre-emption question or (2) find that the Florida Court’s statement was dicta and did not raise a real issue.

Applying Charles:

CPS has always advised its participants to divide their safety and quality work into 3 categories:

  1. Reports that have to be submitted under state or other federal law,
  2. Work that is required to be done and related documents that must be generated but not reported under state or other federal law, and
  3. Work that is not required by other law.


Under Charles, documents produced to meet an independent state law requirement (Category 1) are not eligible to be PSWP. Work product that results from other state-required activities (Category 2) is in a gray zone and the answer may depend on state law and how you have structured the work.  If you have questions, contact CPS.  Review your mandatory activities and reports (bullets one and two above) and design your PSES to include work that is done outside those categories. Your PSES can always consider non-PSWP; the deliberations and analysis within the PSES can be protected, but the non-PSWP work product cannot.

There remains an open issue of admissibility in court for any of this information.  That is another fight for another day.

CPS will keep you advised of new developments.

CPS will keep you advised of new developments.


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.


Later this month is Healthcare Quality Week, sponsored by the National Association for Healthcare Quality (NAHQ).  Use the week to recognize healthcare quality management professionals, healthcare quality achievements in your organization, and raise awareness about the importance of quality in everyday practice.HealthcareQualityWeek_LOGO

We encourage you to take advantage of the free webinars, posters, tips, and templates provided by NAHQ.

Visit their site to learn more about upcoming events and available promotional items.

Maintain the focus after Healthcare Quality Week.  Set goals based on NAHQ recommendations:

  1. Build and maintain a strong culture to continuously improve quality of care and optimize patient safety.
  2. Establish accountability for integrity of quality and safety programs
  3. Create systems to continuously improve.
  4. Report quality and safety data accurately.
  5. Remove barriers to success.





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?


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.