Provide Feedback to Extra Line Staff

Feedback to the front-line staff is a critical component of demonstrating a commitment to safety
and ensuring that staff members continue to report safety issues. This Institute for Healthcare
Improvement Web page identifies tips and tools for how to communicate feedback.

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.


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.