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)

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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.


CPS Safety Watch/Alert: Meningitis from Steroid Injection Medication

Meningitis from steroid injection medication continues to be a concern with 205 cases in 14 states, resulting in 15 deaths thus far.  The medications were distributed to 23 states. The CDC provides the details and the latest information:

Multistate Fungal Meningitis Outbreak Investigation.” Centers for Disease Control and Prevention; dated 15 Oct, 2012. Web.


Joint Commission Issues New Sentinel Event Watch/Alert: Opioid Use

The Joint Commission has issued a new sentinel event alert: Safe Use of Opioids in Hospitals.   Although hospital patients may need the strong pain relief that only opioids can provide, a Sentinel Event Alert issued yesterday by The Joint Commission urges hospitals to take specific steps to prevent serious complications or even deaths from opioid use.   MORE

CPS Safety Watch/Alert: Fatigue Impacts Patient Safety

The link between health care worker fatigue and patient safety is not unfamiliar. But have you assessed your organization to mitigate health-care worker fatigue-related risks? The Joint Commission suggests the following: a review of the work shift schedule with staff involvement; an assessment of high-risk processes and procedures (such as patient hand-offs); education on sleep hygiene (getting enough sleep and practicing good sleep habits that can impact sleep); and promotion of a safe culture through open communication about fatigue concerns as well as a focus on teamwork to support staff working extended hours. The result of these efforts can protect your patients from harm.

Read more about what you can do in Issue 48 of the The Joint Commission Sentinel Event Alert.

For more information, check out our links to several Communication & Teamwork Toolkits!

Interested in finding out what your safety culture is? Check out the Survey on Patient Safety Culture!

Voluntary Recall by H&P Industries

The FDA has initiated the recall of all lots of Povidone Iodine Swabsticks, Povidone Iodine Prep Solutions, Povidone Iodine Scrub Solutions, and Povidone Iodine Prep Gel.   To determine if you are using any of these items and information on return arrangements, check the full press release.


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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