Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management

This page of resources was developed by the Institute for Healthcare Improvement. IHI
periodically receives urgent requests from organizations seeking help in the aftermath of a
serious organizational event, most often a significant medical error. In responding to such
requests, IHI has drawn on learning and examples assembled from many courageous
organizations over the last 15 years who have respectfully and effectively managed these crises.

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems

The National Association for Healthcare Quality Call to Action: Safeguarding the Integrity of
Healthcare Quality and Safety Systems provides best practices to enhance quality, improve
ongoing safety reporting, and protect staff. It addresses accountability, protection of those who
report quality and safety concerns, and accurate reporting and response.

BLOG:

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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RESOURCES:

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.