Patient Safety Workshop – Learning From Error

Developed by the World Health Organization, this patient safety workshop is designed to be
suitable for health-care workers (e.g. nurses, doctors, midwives, pharmacists), health-care
workers in training (e.g. nursing students, medical students, residents), health-care managers or
administrators, patient safety officers, and any other groups involved in delivering health care.
The workshop explores how multiple weaknesses present within the hospital system can lead to
error. It aims to provide all health-care workers and managers with an insight into the underlying
causes of such events. Workshop, participants should be introduced to an understanding of why
errors occur; begin to understand which actions can be taken to improve patient safety; be able to
describe why there should be greater emphasis on patient safety in hospitals; and identify local
policies and procedures to improve the safety of care to patients.

Hand Hygiene in Healthcare Settings

The Centers for Disease Control and Prevention’s Hand Hygiene in Healthcare Settings provides
healthcare workers and patients with a variety of resources including guidelines for providers,
patient empowerment materials, the latest technological advances in hand hygiene adherence
measurement, frequently asked questions, and links to promotional and educational tools
published by the WHO, universities, and health departments.

Overall Perceptions of Patient Safety: Central Line Insertion Checklist

This checklist is used to document activities that are considered standard practice in a critical
care unit before, during, and after a central line procedure. It helps to ensure that all processes
related to central line placement are executed for each line placement, thereby leading to a
reliable process.

AHRQ Patient Safety Education and Training Catalogue

The Agency for Healthcare Research and Quality’s Patient Safety Education and Training
Catalog consists of patient safety programs currently available in the United States. The catalog,
which is featured on AHRQ’s Patient Safety Network, offers an easily navigable database of
patient safety education and training programs consisting of a robust collection of information
each tagged for easy searching and browsing. The new database identifies a number of
characteristics of the programs, including clinical area, program and learning objectives,
evaluation measures, and cost. The clinical areas in the database align with the PSNet

Conduct Patient Safety Leadership WalkRounds™

Appoint a Safety Champion for Every Unit

Teamwork Within Units – Crisis Management Simulation Course Receives Positive Reviews, Enhances Communication and Teamwork Among Labor and Delivery Practitioners During Crises

This featured profile is available on the Agency for Healthcare Research and Quality’s Health Care Innovations Exchange Web site. Crisis Resource Management (CRM) is a 7-hour course for labor and delivery (L&D) practitioners. It uses various strategies of crew resource management, a safety program developed by the aviation industry, to create realistic simulations designed to facilitate improvement of teamwork and communication skills in a real L&D crisis. According to post implementation surveys, the course is highly regarded by the vast majority of participants. Surveys conducted 1 or more years after the course suggest that it produces lasting benefits, including improvements in communication, team leadership, and team performance during crises.


Teamwork within Units (CUSP)

The Comprehensive Unit-based Safety Program (CUSP) toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety.


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.