Door-to-Doc Patient Safety Toolkit

Door-to-Doc is a patient flow redesign process that improves the safety of care for patients in the
emergency department by reducing the time patients wait to be seen and by expediting admission
to the most appropriate hospital unit. A main feature is that patient flow is split into “less sick”
and “sicker” patient subgroups based on a “quick look” rather than a full triage. This has the
advantage of keeping less sick patients, which is the vast majority, flowing (rather than waiting
in the lobby) during busy times.

Coordinated-Transitional Care Toolkit

This tool was developed by the University of Wisconsin-Madison School of Medicine & Public
Health and the William S Middleton Memorial Veterans Hospital. The Coordinated-Transitional
Care (C-TraC) Toolkit is a low-resource, telephone-based, protocol-driven program designed to
reduce 30-day rehospitalizations and to improve care transitions during the early post-hospital
period. The goal of this toolkit is to help hospital systems that serve populations with high rates
of patient dispersion, cognitive impairment, and vulnerability improve care coordination and
post-discharge outcomes such as reduced medication discrepancies. The toolkit is designed to
help clinicians and researchers execute the C-TraC program protocol. In addition to the full
toolkit, C-TraC developed a COMPASS module to support hospital to nursing home transitions.


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.