CPS Safety Watch/Alert: Patient Destination Decisions

Thousands of patients are treated and transported by EMS to a destination hospital every day. Most hospitals can meet the required needs of EMS patients; however, patients who have certain conditions, i.e. Stroke, STEMI, Trauma or Pediatrics, often require more specialized care as quickly as possible. These patients have time sensitive conditions called Time Critical Diagnosis (TCD).

TCD is about:

  • Early Identification
  • Appropriate Treatment
  • Appropriate Destination

Many EMS leaders, hospitals and other stakeholders have adopted the TCD concept of. This approach allows for specialized treatment when minutes matter. (more…)

CDC Urging Dialysis Providers and Facilities to Assess and Improve Infection Control Practices to Stop Hepatitis C Virus Transmission in Patients Undergoing Hemodialysis

The CDC issued a health advisory urging dialysis providers and facilities to assess and improve infection control practices to stop Hepatitis C viral transmission in patients undergoing hemodialysis. A health advisory may not require immediate attention but provides important information for a specific incident or situation.

The CDC received an increased number of reports of HCV infections between 2014 and 2015 associated with hemodialysis clinics in eight different states.  While investigations are ongoing initial evaluation demonstrated lapses in infection control associated with these infections. (more…)

CPS Safety Watch/Alert: EKG strip

Safety Watch - buttonThe Center for Patient Safety is issuing a PSO Watch in regards to documentation/chart accuracy. An event was shared where there was confusion regarding the appropriate identification of a patient’s EKG strip, resulting in a patient being treated for a dysrhythmia they did not have. This event brought to light many difficulties currently faced by hospitals and EMS providers:

  • Many hospitals are still in the process of transitioning from paper charts to electronic charts, causing confusion with processes.
  • In the hospitals, most units have systems that automatically print patient labels, or have patient names on EKG strips.
  • The ED departments and EMS agencies have very different systems to label orders/tests/blood work/EKG strips which causes confusion and communication breakdown.

To improve accuracy of patient documentation and communication between departments, CPS recommends the following:

  • Review processes for labeling documentation, and labeling placement, in the chart
  • Ensure standardization of processes
  • Reach out to other departments to ensure processes are standardized throughout system
  • Utilize standardized tool for communication/handoff of patient and test results

CPS Safety Watch/Alert: Intranasal Medication Administration

Safety WatchBased on industry data and recent findings from event data submitted to the PSO, the Center for Patient Safety is issuing a Safety Watch about intranasal medication administration.


Recently, an EMS provider mistakenly administered a medication intranasally when it should have been administered by IV route only. There were was no harm reported to the patient, however, the patient didn’t receive the therapeutic effects desired. This safety watch is to remind providers that not all medications are approved for intranasal administration and dosing can be different from other routes.

Intranasal medication administration is a safe and effective means of administering medication. This administration procedure offers many benefits including ease in administration,rapid absorption and no requirement for intravenous access. On a daily basis, EMS professionals use the intranasal route to save lives and reduce pain, however, not all medications can be administered intranasally.

An incorrectly administered medication can occur at any time, however, most medication errors reach the patient when there is no crosscheck process.

To mitigate and prevent future events, the Center recommends that the five medication rights be followed. In addition, develop a process to support providers with a cross check or medication read back procedure. Always follow medical direction and established protocols. As with all medication administration, the provider should insure the five rights:

  1. Right Dose
  2. Right Patient
  3. Right Route
  4. Right Time
  5. Right Drug

Therapeutic Intranasal Drug Delivery – http://intranasal.net/
Sedgwick County Medication Cross Check Video – https://www.youtube.com/watch?v=qktIdQ86piI

CPS Safety Watch/Alert: Reprocessed Flexible Bronchoscopes Pose Risk

PSOAlert!On September 17, 2015 the FDA issued a safety communication on “Infections Associated with Reprocessed Flexible Bronchoscopes”, following its earlier communication about similar concerns with duodenoscopes/endoscopes.
This alert is to reinforce the following highlights of the report, encouraging healthcare
providers to review processes and implement steps to ensure the safety of patients:

  • Bronchoscopes are a subset of devices that pose a high risk of infection if not adequately reprocessed.
  • Between January 2010 and June 2015 the FDA received 109 Medical Device Reports (MDRs) concerning infection/device contamination associated with flexible bronchoscopes.
  • In 2014 alone the FDA received 50 MDRs concerning infection/device contamination associated with flexible bronchoscopes that prompted further investigation.
  • A small number of MDRs document device contamination despite following manufacturer’s reprocessing instructions. These reports are still being investigated.

The complete report is available here.

The earlier published FDA communications addressed concerns about:

  • The complex design of ERCP endoscopes (duodenoscopes) providing a challenge to cleaning and high-level disinfection.
  • Potential for residual body fluids/organic debris to remain in the microscopic crevices of the moving parts of the elevator mechanism and expose patients to serious infections.
  • Seventy-five MDRs received between January 2013 and December 2014 related to potential microbial transmission from reprocessed endoscopes/duodenoscopes.
  • Instances of device contamination despite strict adherence to manufacturer’s reprocessing instructions.

Complete information from the FDA on these concerns are available at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm and http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm454766.htm.


  • Strict adherence to the manufacturer’s reprocessing instructions
  • Immediate removal of use of any bronchoscope that fails a leak test or shows visible signs of damage
  • Conduct maintenance and repair according to manufacturer’s recommendations
  • Implement a comprehensive reprocessing quality control program
  • Store bronchoscopes in a manner so as to minimize the risk of contamination


CDC/FDA Health Update about the Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices:  http://emergency.cdc.gov/han/han00383.asp.

CPS Safety Watch/Alert: Expressed Breast Milk

Today, the Center released a Patient Safety Watch: Expressed Breast MilkSafety-Watch-09.28.2015
We encourage you to review the watch and share with others in your organization.

The Center for Patient Safety (CPS) is issuing a PSO Watch to raise awareness about the effects of providing expressed breast milk to the wrong infant, otherwise called “mixing up” breast milk. ECRI Institute recently published a newsletter article and referenced a significant number of events which involved the use of “mixed up” breast milk. CPS has also received a number of similar reports. Read more: download the Watch.

If you have questions, please contact any of the Center’s PSO Team members.

CPS Safety Watch/Alert: Missing & Lost Equipment in EMS

Attention EMS PSO Participants:

Safety Watch 08.25.2015The Center for Patient Safety is issuing a PSO Watch for Missing Lost Equipment in EMS
Missing and lost emergency equipment is a common occurrence in EMS as indicated by events recently reported to the CPS PSO and concerns voiced from EMS leaders. Without the proper equipment immediately available, unnecessary harm might reach a patient. The Center for Patient Safety is issuing this Safety Watch to remind EMS providers and leaders about the potential risks associated with missing equipment. This is a call to action to prevent risk and patient harm.

CPS Safety Watch/Alert: Prevent Violent Behavior

Safety-Watch-07.15.2015editThe Center has released Patient Safety Watch: Prevent Violent Behavior.  We encourage you to review the watch and share with others in your organization.

The incidence of physical and violent behavior continues to rise across the United States, and reports in the Center for Patient Safety’s PSO database support this trend. Events include throwing furniture, biting, hitting, verbally abusing and physically attacking employees. Although most of the events resulted in no harm, it’s important to learn from these incidents and take action before employees, patients and visitors are injured.  Read more: download the Watch.

CPS Safety Watch/Alert: Prevent Fatal Medication Errors

The National Alert Network recently issued an alert based on a fatal medication error where a nurse confused fluid drams with mL.  While the healthcare system bases most of its medication on the metric system, many measuring cups utilized for liquid medication not only still have drams listed, but also ounces listed.  Harm could be prevented by the utilization of dosage cups that only measure liquids in the metric system.  Read the full alert.

CPS Safety Watch/Alert: High Alert Medications

PSOAlert!The Center for Patient Safety is issuing a Safety Alert based on industry data and recent findings from event data being submitted to the PSO.  The following areas of concern have been reported to the PSO:

  • A pediatric patient receives a higher than standard dose of Propofol and requires resuscitation.
  • A battery fails on an insulin IV pump and goes unnoticed.
  • Approximately one in every five reported PSO medication events involves a high alert medication such as anticoagulants (warfarin, heparin, Lovenox), Propofol, insulin, hypoglycemic agents, opioids and so forth. Events relate to prescribing, dispensing, administering and monitoring errors.


The #1 topic they didn’t teach you in Paramedic School: Culture:

I have been working with the Center for Patient Safety (CPS) for about four months, and I’m learning something new every day.  As a Paramedic, patient safety has always been a high priority, but I didn

ISMP Update on Top Medication Safety Issues from 2018 – Webinar:

Medication mistakes are one of the most common errors reported to the Center’s PSO.  ISMP is offering a free webinar on November 15 at noon Central Time to discuss the top medication safety issues as we

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

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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.