Recognizing Fall Prevention Week

Fall Prevention Awareness Week started Saturday, September 22 and runs until Friday, September 28. Stopfalls.org has excellent resources and tools to support ongoing efforts including flyers, posters, fact sheets and videos. A fall can result in injury, trauma and even death. Sometimes the fall isn’t even the scariest part and it is the post-fall events of surgery, immobility and potentially pneumonia that result in death.

Like many baby-boomers, my mother is the caretaker for my grandmother. Now in her 90s, my grandmother is sharp as a tack, witty, and full of life, however, she is also very frail and purposeful in her movements. My mother lives in a two-story Cape-style home and serves dinner in her dining room, requiring my grandmother to venture down a flight of stairs from her bedroom. My mother’s husband has a coordinated drill with my grandmother that I always enjoy watching when I’m around. He takes her arm gently in his, stands beside her and they descend slowly and methodically down the stairs, one at a time, as if they were a single person. He matches his stride to hers, paying close attention to her hesitations, much like a dance partner. While he initially started doing the “stair dance” as a supportive function, he is actually preventing her from falling.

Not all older adults have a stair dancing partner, so it’s important to find another effective method of fall prevention. In a home with more than one floor, an electronic stair-lift may be appropriate if arrangements cannot be made for the individual to live fully on one floor. Recognizing trip hazards is also very important. My mother has three cats, so it’s necessary to ensure a cat is not underfoot when my grandmother moves about.

We are likely all familiar with an aging family member that is at risk of a fall. No matter how adamant they are about living on their own or continuing their daily routines without worry, any of us that work in healthcare recognize the serious risks. We want to protect our parents, our grandparents, or even our great-grandparents, but we must also respect their desires if they choose to age in their homes, even if they are doing so alone. Engage them in the conversation and review the checklists on stopfalls.org, watch videos together and let them know you care about their safety.

Patient Safety Awareness Week is March 11-17, 2018

Patient Safety Awareness Week (PSAW), an initiative from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement, is designed to raise patient safety awareness among healthcare providers and consumers. This year, PSAW is March 11-17. It’s a great time to celebrate successes and re-focus on patient safety opportunities in your organization. The Center encourages providers and consumers to obtain information about patient safety issues. Below are highlights of Patient Safety Awareness Week activities.

Take advantage of the following resources and conferences to help launch a successful campaign! The Center’s highly anticipated Patient Safety Toolkit will be available for download by CPS Subscribers.

Join us on social media and check out these patient safety resources and tips we’re sharing during #PSAW2018!


Patient Safety Forum, March 14, 2018

Everyday across the country, healthcare is provided in many clinical settings and environments.  Likewise, the healthcare landscape is complicated as it evolves at an ever-quickening pace with new specialties, titles and tools.  Coupled with the growing demands placed on clinicians and healthcare leaders, how do we ensure the safety of our patients?  Join us for this collaborative opportunity to learn with other providers across the continuum of care how patient safety can be improved.
Added Bonus! All attendees of the forum will become a Subscriber to CPS’s online resource center, which provides toolkits, special previews to upcoming events, and a community forum. Find out more about becoming a subscriber!

Learn more about the Forum


Second Victim Experience, March 19, 2018

Most health care providers adjust well to the multitude of demands encountered during an unexpected or traumatic clinical event. Providers often have strong emotional defenses that carry them through and let them “get the job done.” Yet sometimes the emotional aftershock (or stress reaction) can be difficult. Signs and symptoms of this emotional aftershock may last a few days, a few weeks, a few months, or longer.

Added Bonus! All attendees of the workshop will become a Subscriber to CPS’s online resource center, which provides toolkits, special previews to upcoming events, and a community forum. Find out more about becoming a subscriber!

Learn more about the Second Victim Workshop


The CPS Patient Safety Improvement Approach

The Center for Patient Safety believes every patient safety improvement journey includes an evaluation of your current culture. It’s important to use meaningful data to understand how staff perceive the organization’s approach to patient care. Our bundled approach gives you peace of mind that you’re working with the patient safety experts – and we want YOU to be successful!

Step 1: CPS administers a survey to your staff and provides a detailed interpretation of your results.
Step 2: We work closely with you to develop your action plans and next steps.
Step 3: Our work continues with you over the next six months to a year to provide education and training, workshops, resources and tools. We support you in reaching your goals!
Learn more about the CPS Patient Safety Approach through Culture Change

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]).

Falls Prevention Awareness Day is Sept 23, 2014

From the Center for Healthy Aging, National Council on Aging (NCOA):

Strong Today, Falls Free ® Tomorrow

Date: September 23, 2014

The 7th annual Falls Prevention Awareness Day will be observed on September 23, 2014-the first day of fall. This year’s theme, Strong Today, Falls Free ® Tomorrow, seeks to raise awareness about how to prevent fall-related injuries among older adults.

The Falls Free ® Initiative is a national effort led by NCOA to address the growing public health issue of falls and fall-related injuries and deaths in older adults.

Primaris Webinar Explains the Safety Culture Survey

On September 25 at 1 p.m., Primaris will host a webinar for its QAPI Learning and Action Network about the SOPS Survey of Resident Safety Culture. Kathy Wire and Alex Christgen will describe the survey itself and how easy it is to participate through the Center for Patient Safety.   And remember, the Survey is provided at no charge for Missouri licensed long-term care providers. Providers who are participating in the LAN can register for the webinar and get more information here.

CPS Rolls Out Long-Term Care Safety Culture Survey

As long-term care providers move headlong into one kind of culture change, along comes Safety Culture.  Is there a tool to measure it and help define it-a Safety Culture version of the Artifacts of Culture Change?   Yes, there is.   It’s the Survey of Patient Safety Culture from the Agency for Healthcare Quality and Research (AHRQ).   And Missouri licensed long-term care providers can administer it simply and at no cost through the Center for Patient Safety (CPS).   Learn more about the survey process and how to sign up here.

Visit CPS at the LeadingAge Missouri Fall Annual Conference

CPS will have a booth at the LeadingAge Missouri Fall Annual Conference September 18-20 at Lodge of the Four Seasons. Come see us and let us know how we can help your Missouri-licensed long term care organization improve resident safety and support your compliance with the anticipated QAPI regulations!

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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.