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:  http://www.cdc.gov/HAI/outbreaks/meningitis.html

Multistate Fungal Meningitis Outbreak Investigation.” Centers for Disease Control and Prevention; dated 15 Oct, 2012. Web.  http://www.cdc.gov/HAI/outbreaks/meningitis.html


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.


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

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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.