CPS Safety Watch/Alert: Endotracheal Intubation in EMS

Safety WatchThe Center for Patient Safety is issuing a Safety Watch 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:

  • Tube dislodgement during patient movement
  • Patient aspiration
  • Rapid Sequence Intubation

CPS Safety Watch/Alert: Medications – Bloxiverz v Vazculep

ISMP Medication Safety Alert for Hospitals, ASCs and anesthesia professionals! Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. ISMP is alerting hospitals, ambulatory surgical centers, and anesthesia professionals about the potential for dangerous mix-ups between two relatively new presentations of older medications, neostigmine injection and phenylephrine injection.Read more.

CPS Safety Watch/Alert: Cricothyrotomy

Safety Watch
This Safety Watch is to advise you that having multiple different types of cricothyrotomy kits can lead to confusion during an airway emergency. We believe standardizing your equipment including cricothyrotomy kits within an organization or within a region would help to reduce the likelihood of an adverse event.

Cricothyrotomy also commonly called a “cric” is an emergent procedure for establishing an immediate airway.  The procedure can be performed several ways with various commercially prepared kits or with specialty prepared equipment. The skill requires the provider to access the cricothyroid membrane to establish an airway for oxygenation and ventilation.

Possible reasons for these events:

  • Access to different types of kits can lead to confusion during an airway emergency

CPS Safety Watch/Alert: Morphine vs Midazolam

PSOAlert!The Center for Patient Safety has released a PSO alert regarding the potential for confusion when administering Midazolam or Morphine.

As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including EMS medication events.

Recently, there has been a trend of medication errors pertaining to the administration of the incorrect medication involving Morphine and Midazolam.   Specifically, confusing the two medications and administering the wrong medication.

Possible reasons for the error:

  • Similar names of medication
  • Similar packaging or container
  • Similar route of delivery
  • Medications were locked together
  • No cross check process in place or time out taken before administration

CPS Safety Watch/Alert: EMS Stretchers

Safety WatchMultiple stretcher-related incidents have been reported to the Center’s Patient Safety Organization.   The areas of concern are from real events.

Released 08.11.2014.

CPS Safety Watch/Alert: Inaccurate Data Source for Surescripts Services Potentially Impacting Patient Safety

National Alert Network Issues Alert on Surescripts “Medication History Acute” and “Medication History Ambulatory” services containing inaccurate information.

The National Alert Network has issued a new alert pertaining to the data source for Surescripts’ “Medication History Acute” and “Medication History Ambulatory” services potentially containing inaccurate information that could jeopardize patient safety. The Network indicates that the potential inaccuracy relates to the strength of a drug reported in the medication history drug description field, and results from missing special characters such as a decimal point, forward slash, or percentage in some records. The Alert also indicates that Surescripts has disconnected the data source from the services until corrected, and communicated the potential risk to all EHR vendors. The alert advises health care professionals to “question and confirm any medication dosages reported in electronic medication history information that appears inappropriate given the patient’s unique characteristics and current health status.” Health care providers are also encouraged to contact their EHR vendor to determine if the issue affects their systems.

CPS Safety Watch/Alert: Preventing Retained Surgical Items

The Center for Patient Safety and The Joint Commission have released alerts regarding the preventing of retained surgical items. The alerts reflect data the Center for Patient Safety (CPS) is seeing.

As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including retained surgical items (RSI). RSIs are unintentionally retained objects from an invasive procedure.

While RSI events do not occur often, they still happen. In cases of RSIs, the item is often discovered and removed right away. However, this requires additional surgical procedures, can cause the patient undue strain and may extend their recovery time.

PSO data reveals the most often reported retained items are sponges and guide wires, but other cases include broken surgical items like drill bits, and parts of instruments and devices.


PSO WATCH/ALERT! Need for Clear Policies and Educated Defense Counsel

New Kentucky Appeals Court Decision Underscores the Need for Clear Policies and Educated Defense Counsel

(Mercy Health Partners-Lourdes, Inc. v. Kaltenback, No. 2013-CA-000053-OA, entered July 11, 2013)

Download a printable version

The Center’s participants have heard us preach about defining clear boundaries for their Patient Safety Evaluation Systems (PSES) and implementing clear PSES policies.   Courts will examine these policies closely in determining whether information generated as part of patient safety activities can be protected as Patient Safety Work Product (PSWP).   They will also examine the path of purported PSWP to see if the organization has followed its own policies for protected information. (more…)

CPS Safety Watch/Alert: Glacial Acetic Acid Solutions not recommended for patient care

The National Alert Network (NAN) has released a warning regarding the potential for severe patient burns and scarring from “accidental application of ‘glacial’ acetic acid (less than or equal to 99.5%) to skin or mucous membranes instead of a much more diluted form.   Glacial acetic acid is the most concentrated form of acetic acid available.”   The article recommends replacing current stocks of glacial acetic acid with vinegar or a commercially available diluted acetic acid, educating staff about the differences between glacial acetic acid and diluted acetic acid, and put safety guards in place to restrict purchasing.   Read the full alert

The NAN bases alert information on errors reported to the National Medication Errors Reporting Program and is operated by the Institute for Safe Medication Practices.

CPS PSO-WATCH/ALERT! Ambien Sleep Aid Associated with Increased Fall Rate

PSO Alert:   The Center for Patient Safety is issuing an alert to all healthcare providers that may currently be using Ambien as a sleep aid for their patients.   This includes but is not limited to hospitals, long term care, and nursing home affiliates.

The Mayo Clinic announced last week in “Health Day News” that a study involving 16,000 inpatients showed the fall rate for those taking Ambien as a sleep aid quadrupled, compared with patients not taking the drug.

Read the full PSO Alert.



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.