Sean Berenholz, MD – Johns Hopkins

Comprehensive Unit-based Safety Program (CUSP) & Health-care Acquired Infection (HAI) Prevention

Hospital Acquired Infections, HAIs, take more lives each year than breast cancer and HIV combined. Read more below.

Through an AHRQ grant, Johns Hopkins and Michigan Health & Hospital Association Keystone Center, Sean Berenholtz is working with a team of dedicated professionals to address Hospital Acquired Infections €“ an effort which has been led in Missouri by the Missouri Center for Patient Safety in collaboration with the Missouri Hospital Association.

What was learned from the study may be divided into 3 fundamental principles:

  1. Frontline health care providers are the key to improving patient safety .
  2. The vast majority of HAIs result from a problem with the health care system as a whole, and not individual doctors or nurses.
  3. Healthcare acquired infections can be reduced to zero, and these results that can be replicated across the nation.

Published results of the Keystone Project demonstrate such collaborative efforts can significantly reduce HAIs.  In Michigan, 100 ICUs initially reduced central-line blood stream infections (CLABSIs) by 60%, and sustained the reduction over three years.  This work is attributed to a 10% reduction in death rates in participating hospitals.  Similar work in Rhode Island led to a 70% reduction in CLABSIs.  This work is now being performed in 47 states in 1000 hospitals, including Missouri.


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.