Experiencing Medical Errors

Some of the most stirring reports of medical errors come from medical professionals who find themselves to be victims. In this story, a pediatrician receives epinephrine via the wrong route.  Her biggest disappointment?  That the system cannot improve.

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CPS Partners with Verge Health to Improve Patient Safety

Verge Manages Technology while CPS Provides Consultancy Services

On the heels of Patient Safety Awareness Week, Verge Health, a leader in healthcare risk management, has partnered with the Center for Patient Safety (CPS), a non-profit organization envisioning a healthcare environment safe for all patients and healthcare providers, in all processes all the time.

“The shift to value-based care, and the vast expansion of data sharing among and between health systems, presents both risk and opportunity,” says Mark Crockett, chief executive officer of Verge Health. “We are delighted to solidify our working relationship with CPS to help improve safety by leveraging technology to help protect patients.”

Under terms of the agreement, the two companies will partner to promote products, services, and events to their respective client bases promoting the shared vision of protecting patients and margins. The agreement formalizes a long-time relationship where Verge powers the CPS PSO, and CPS offers PSO services, consultation and education around patient safety culture.

“From conducting patient safety assessments to helping hospitals and other health care organizations improve patient safety, we generate a significant amount of data that must be kept secure while being accessible,” says Alex Christgen, Executive Director for the Center for Patient Safety. “We’ve been working with [Verge] for several years to support our Patient Safety Organization, and believe our patient safety vision fits well with the IT platforms that Verge provides.”

About Verge Health
Founded in 2001, Verge Health is a risk management software company. Verge Health’s software solutions enable healthcare organizations to proactively protect and defend patients, caregivers, and frontline staff, against errors, adverse events, and policy violations. With over 900 facilities and 500,000 active users, the company’s Converge Platform provides hospital organizations with a cross-functional, proactive surveillance tool enabling optimal quality and safety results. For more information, please visit https://www.vergehealth.com/

About Center for Patient Safety
The Center for Patient Safety, is a private, not-for-profit corporation dedicated to fostering change throughout the nation’s health care delivery systems and across the continuum of care. It provides patient safety services to more than 1000 health care facilities across the nation since its inception 12 years ago, which was in response to recommendations from the Missouri Governor’s Commission for Patient Safety. For more information, go to

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.









Are Critical Thinking Skills Becoming Extinct?

As an RN for nearly 30 years, I’ve seen many changes in the healthcare arena since I started as a Student Nurse Assistant in 1986. I recently had a discussion with other healthcare providers regarding the identification of patients with sepsis. The topic of young healthcare providers lacking critical thinking skills came up. This is a conversation that I’ve had with multiple healthcare providers over the past few years, but this time it just really frustrated me. The conversation brought up many potential contributing factors, such as patients entering the hospital more acute than they have been historically; shorter duration of hospital stays; and the emergence of technology.  After the conversation I began thinking that maybe today’s generation of healthcare providers is disadvantaged in that documentation is electronic and mainly checkboxes, placing a reliance on technology.  My theory is that maybe there is an association between actual writing, and learning the relationships and associations that are the foundation for critical thinking skills.

I began thinking of my own career as a Neonatal ICU nurse and remember how the first institution I worked at required an environmental assessment ….gasp…handwritten (actually EVERYTHING was handwritten, I even had a color coded pen, one color for day shift, another for evening and another for night) at the beginning of every shift. So, I had to start off my shift writing:  “Received infant in “name of warmer bed brand/isolette brand” set on “manual mode/servo mode” set at “__”. Infant on “type & brand of ventilator” settings at “list the settings” with “self-inflating bag or anesthesia bag at bedside.”  Infant attached to “brand of monitor” with heart rate alarms set at “…”, respiratory rate alarms set at “…”, B/P alarms set at “…” and O2 sat alarms set at “…”.”  Anyway, I think you get the idea.  But the point is that writing this assessment set into motion relations between what I was writing/observing and the condition of the infant.  It started the foundation for that “critical thinking process.”  I remember learning through writing my observations/assessment on a premature infant the association between hypothermia and hyperglycemia…that it usually meant the infant was stressed and we (the healthcare team) needed to be assessing possible causes. So going back to my theory of recognizing relationships/associations through writing what you’re observing had me going to Google (yes, I confess to absurd love of Google for all my questions!). What I found was a multitude of articles supporting my theory that writing notes does help your brain develop relationships and associations.  Now granted a Google search is definitely NOT scientific research of any kind, but it does provide a starting point.

That leads me to wondering how we can help the upcoming generation of healthcare providers develop these critical thinking skills. Technology is here to stay and to be honest I think it’s a good thing! But, I can see where the above mentioned factors can put up a barrier into the development of critical thinking skills.  Patients are more acute, they usually have a multitude of diagnosis, not just one.  The stay in the hospital is also shorter, which actually means that healthcare providers need to have those critical thinking skills as the opportunity to observe/assess your patient is shorter. So my question to other healthcare providers is threefold:

  • What do you think? Are critical thinking skills becoming extinct?
  • If so, what are some potential solutions to help develop critical thinking skills?
  • How can we leverage technology to assist with the development of critical thinking skills?

The Chronic Problem of Communication

I saw this article come across my morning email news and was immediately drawn in as communication is not just a problem in hospitals, but in every healthcare environment. Having traveled throughout the United States in my nursing career and delved into a variety of nursing fields, I can honestly say that more than once in every position I’ve held, an issue involving patient safety has cropped up, mainly due to a failure to communicate.

The word “communication” originates from the verb “communicare” which means to share.  This is so true when you think about what you should be doing when as a healthcare professional you are communicating with another healthcare professional.  You are “sharing” information.  But even more, while the word itself has a variety of technical definitions, the definition I like best is “the successful conveying or sharing of ideas and feelings.” I think because this definition puts an emphasis on “successful”.  One healthcare professional can share information with another, but it’s that double-checking to confirm that information or concerns were heard and successfully conveyed that healthcare needs to improve.

Take a few moments today and review your handoff processes within your organization.  Whether it’s when a patient leaves your area to go to another area or even when an employee just leaves for lunch or a break.  What is the process?  How do you share information?  And most importantly, are you keeping the patient and patient’s safety as a top priority. Read article.

“Do it For Drew”

Whether you are a provider, educator or medical director take a few minutes and read this important article in EMS1.com called “Do it For Drew”.  This is a story that highlights why patient safety is important in EMS and should be at the core of our education and daily practice. Read article.

TJC Sentinel Event Watch/Alert: Preventing falls and fall-related injuries in healthcare facilities

Prevention of falls according to The Joint Commission can be a difficult and complex process. While falls resulting in death/serious injury are considered to be never events, since 2009 there have been 465 such cases reported.  The most common contributing factors include:  inadequate assessment; communication failures; lack of adherence to protocols and safety practices; inadequate staff orientation, supervision, staffing levels or skill mix; deficiencies in the physical environment and lack of leadership.  Strategies outlined for prevention of falls include the following: raise awareness; establish a multi-disciplinary fall prevention team; utilize standardized/validated tools for fall risk assessment; develop patient-specific care plans; standardize practices such as hand-off communication processes, conduct post-fall huddles and continually re-assess the patient. Also of interest is that an article was recently published noting that infections can be an underlying cause of falls.  Read the full article.

Read more on falls and fall prevention in Issue 55 of The Joint Commission Sentinel Event Alert: http://www.jointcommission.org/assets/1/18/SEA_55.pdf

For more resources on fall prevention please check out this PSNet page: https://psnet.ahrq.gov/resources/resource/29414

EMS Clinicians Can Combat Fatigue

EMS clinicians are highly susceptible to fatigue due to long shifts, stress, and other sleep-impacting issues and the Center for Patient Safety recognizes fatigue is a causal factor for many clinician and patient-related events in EMS.  There is a way to combat fatigue through cultural improvements including the adoption of fatigue management policies.

A recent article in EMS1.com reviews evidence-supported countermeasures for fatigue among EMS providers.  Countermeasures include adequate sleep, naps/rest breaks, physical exercise, reduced caffeine consumption, and engage in mental exercise.  The article suggests, “[a]dministration should adopt a process that promotes reporting fatigue without fear of penalty or reprisal. A process for investigation of events potentially related to fatigue is important for evaluation and improvement.”

Interested in adopting a culture that supports and encourages the reporting of errors? 

Learn more about Just Culture or read the “Strategy for a National EMS Culture of Safety” from the National Highway Traffic Safety Administration (NHTSA), with support from the Health Resources and Services Administration’s (HRSA) EMS for Children (EMSC) Program, and the American College of Emergency Physicians (ACEP).

Stop the Spread of Antibiotic Resistance – A Call to Action from the CDC

Premier’s latest SafetyShare highlights the CDC’s August Call to Action, Stop the Spread of Antibiotic Resistance.  Did you know more than 2 million illnesses and at least 23,000 deaths are caused each year in the US from antibiotic resistance germs?  Up to 70% of patients could be saved from getting certain infections over 5 years if facilities coordinated prevention activities.?  37,000 lives could be saved from antibiotic resistance infections over 5 years by the appropriate treatment of infection and use of antibiotics. Read more about the CDC recommendations.

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.


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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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.