CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators


  • Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator.
  • Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to experience a lock-up condition after a defibrillation shock was delivered.  This condition is defined as a blank monitor display with LED lights on, indicating power to the device, but no response in the keypad and device functions.
  • The company is contacting customers with impacted devices to schedule the correction of their device(s), which will include an update to the firmware for a component on the System Printed Circuit Board Assembly.


  • If a device exhibits the lockup condition during patient use, the steps from the General Troubleshooting Section (page 10-18) of the LIFEPAK 15 Monitor/Defibrillator Operating Instructions should be immediately followed:
    • Press and hold ON until the LED turns off (~5 seconds) Then press ON to turn the device back on
    • If the device does not turn off, remove both batteries and disconnect the device from the power adapter, if applicable.  Then reinsert batteries and/or, reconnect the power adapter, and press ON to turn the device back on.


CPS Safety Watch/Alert – Violence Against Healthcare Workers

SAFETY ALERT: Violence Against Health Care Workers


  • Verbal Threats
  • Hitting
  • Biting
  • Scratching
  • Kicking
  • Stalking
  • Harassment


  • Review policies and education of staff pertaining to the recognition and de-escalation of hostile and aggressive behavior by patients.
  • Evaluate the need for security personnel and mental health professionals to assist with identification and de-escalation of aggressive behavior.
  • Assess physical work environment to limit/eliminate the possibility of staff working in isolation without escape route in the possibility a patient becomes physically aggressive.


  • Ask your staff if they feel comfortable reporting aggressive behavior
  • Encourage staff to use teamwork strategies such as ensuring a second staff member is readily available to assist with procedures where patients have increased risk of becoming aggressive
  • Leadership should evaluate the culture and consider implementing a support system for staff members who feel threatened/intimidated by patients


Download Here


CPS Safety Watch/Alert – Respiratory Compromise


Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Respiratory Compromise creates problems that are often serious and potentially life-threatening, but they are almost always preventable with the proper tools and approach.  Appropriate patient monitoring and therapeutic strategies are necessary for early recognition, intervention and treatment.

Common themes include:

  • Lack of appropriate monitoring and early identification of respiratory compromise
  • Distractions, complacency or failure to identify high risk patients at transitions of care
  • Not anticipating respiratory complications or lack of situation awareness
  • Complications and risks from procedural sedation


  • Understand the pathophysiology and clinical factors of respiratory compromise
  • Early identification of patients at risk
  • Appropriate and timely patient monitoring
  • Appropriate and prompt interventions and treatment


*Respiratory Compromise Institute

Thanks to Dr. Brian Froelke, CPS


CPS Safety Watch/Alert – Medication Shortages

Medication Shortages:

  • Adversely affect drug therapy
  • Can cause complications in medical procedures
  • Contribute to medication errors
  • Create frustration for providers & patients


  • Validate details of shortage & check with suppliers
  • Determine stock on hand
  • Determine purchase history & true use
  • Estimate time until shortage impacts agency & length of shortage
  • Identify alternative drug and sources


  • Communicate with staff details regarding shortage:
    • Specific drug & effective date/length of shortage
    • Alternative drugs/concentrations
    • Temporary guidelines & processes
  • Utilize teamwork to identify susceptible patient population
  • Review the 5 “R’s” of medication administration (Right medication, Right dosage, Right route, Right patient, Right time)
  • Implement 2-person medication read-back or cross-check policy



Download Printable Version

CPS Safety Watch/Alert: Elopement


  • Nursing, Medical & other Clinical Leaders
  • Clinical Educators
  • Patient Safety/Quality Improvement Leaders
  • Legal/Risk Management
  • And Leaders in:
    • Hospitals
    • EMS
    • LTC
    • Home Care

Safety Watch v4-2 Elopement

Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated with these scenarios include increased risk of:

  • Adverse events
  • Misdiagnosis
  • Mental health exacerbation
  • Diversion which can lead to dangerous delays of care


  • Review/establish an elopement policy
  • Review triage policy/process
  • Identify those at risk for elopement (such as those suffering with psychosis, dementia, drug or alcohol-related conditions)
  • Perform a gap analysis to address issues such as opportunities to reduce risk, assessing staffing, etc.


  • Open Communication: Interview staff to see if they have concerns regarding patient elopement
  • Teamwork: Develop a communication tool that will inform all ED staff of a high risk elopement patient.
  • Share: Openly share peer-reviewed best practices from the literature and processes that have been implemented at your facility or other facilities.



  • Share this watch with the target audience
  • Promote daily safety briefings
  • Continue to share incidents, near misses and unsafe conditions with the Center for Patient Safety

The Joint Commission released Sentinel Event Alert #57

The Joint Commission released Sentinel Event Alert #57 this week:  The Essential Role of Leadership in Establishing a Patient Safety Culture.

The Center for Patient Safety supports the 11 patient safety tenets and provides services and supports to help health care providers across the continuum improve patient safety.  For additional information contact us.

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.









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

CPS Safety Watch/Alert: AHRQ Guidance

Patient Safety Organizations (PSOs) and their participants have struggled with interpreting the Patient Safety and Quality Improvement Act (PSQIA) with respect to handling patient safety work that may be necessary to satisfy mandatory reporting or other operational requirements. In an effort to ease anxiety and develop a common understanding, the Agency for Healthcare Research and Quality (AHRQ) has issued a statement (“Guidance”) on the interface of (1) PSO protection of Patient Safety Work Product (PSWP) and (2) mandatory reporting and operational requirements. AHRQ’s statement is available here. Below are some highlights, based on the questions CPS gets most often from its participants. CPS participants can always contact the Center’s staff with questions.

  • The PSQIA has always required that PSO participants keep the information required to satisfy mandatory reporting requirements outside of the PSWP “protected” space. The Guidance reinforces that requirement. However, the PSQIA and the Final Rule allow participants to gather information inside the PSES until they know whether it will need to be reported. If outside reporting is required, then the information gathered in the PSES that has not yet been reported to the PSO can be pulled back out, so that it can be used to satisfy the outside reporting requirement. The Guidance recognizes both this early PSES protection and the opportunity to pull information from the protected space when necessary.
  • Like the Final Rule, the Guidance emphasizes that analysis that takes place in the PSES cannot be “dropped out.” It must remain as PSWP.
  • If a participant has a known obligation under state or federal law to report certain information, the provider should plan on developing it outside the PSES, as it cannot be PSWP.
  • The Kentucky Supreme Court’s Tibbs decision held that work surrounding mandatory state reporting could not be protected, as the state retained the right to investigate how the provider was accomplishing its reporting obligations. AHRQ’s Guidance seems to question that position, noting instead that information related to the required reporting “form” could be protected once the essential reporting obligation has been fulfilled by submitting the actual form, as long as the original documents from which the report was developed are still available.
  • A variety of projects may take place after a patient safety event. AHRQ’s Guidance contains some helpful examples on pp. 6-7 of how that work can be viewed as inside or outside of the PSES, and when it will have to be non-PSWP because of outside reporting requirements.
  • AHRQ encourages PSOs and their participants to work with state agencies and regulators to determine what information they need access to and what can reliably be viewed as PSWP, so that there are fewer confrontations on the front lines about those issues. (NOTE: CPS has historically supported its participants in this communication wherever possible.)
  • The Guidance emphasizes that PSWP is protected because it has been developed for reporting to the PSO, and that the PSES is a protected space for developing that information. CPS has encouraged its participants to view PSO reporting as the end point of their PSES activities, and to actually report to the PSO. AHRQ’s Guidance underscores the importance of reporting.
  • The Guidance specifically mentions hospitals’ requirement under the Conditions of Participation to track adverse events, noting that there is a “legitimate outside obligation” to keep those records. 42 CFR 482.21(a)(2) (https://www.law.cornell.edu/cfr/text/42/482.21). Incident reports have been a flashpoint in many states with respect to surveyors’ ability to see PSWP. PSO participants should carefully consider what routinely reported event information goes into or out of the PSES.  For example, some PSO advisors recommend that basic incident data that includes just patient name, date, location and a brief description would allow regulators to conduct their own investigations while protecting the PSO participant’s deeper investigation and analysis of those events.
  • The action plans or other actions or changes that result from analysis inside the PSES cannot be protected and can always be shared with surveyors.

CPS Safety Watch/Alert: Contaminated Supply

PSOwatchIt has been reported to the Center for Patient Safety that some organizations have experienced sterile syringes and butterfly needles being contaminated within their sterile packaging.


  • Encourage staff to please be watchful of all sterile packages.
  • If the supplies/equipment are noted to be contaminated, they should not be utilized
  • Remind staff to file a report in your event reporting process to notify leadership
  • Leadership should follow up with the vendor


2019 Missouri Pharmacy Patient Safety Conference:

Join the Missouri Board of Pharmacy and the Center for Patient Safety for the Board’s 2019 Patient Safety Conference.  Together, we can keep Missouri safe one patient at a time.(pharmacists only) T

Are Paramedics Ignoring Hand Hygiene?:

“Many paramedics ignore hand hygiene rules, study finds” A new study looked at hand hygiene practices of paramedics from Finland, Sweden, Denmark and Australia.  The study was featured in Health Daily

CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators:

BACKGROUND: Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator. Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to expe

Read More


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.