TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety

Improving Care Transitions Between Hospital and Home Health: A Home Health Model of Care Transitions

Understanding Care Transitions as a Patient Safety Issue

Home Health and Care Transitions

Hot Topics in Healthcare: Transitions of Care: The need for a more effective approach to continuing patient care

Primaris Complete Pressure Ulcer Prevention Toolkit

This toolkit will help your team comprehensively evaluate your prevention and treatment of pressure ulcers and provide guidelines for implementing best practices. Tools are organized under the following categories.
-Guidelines and Example Policies
-Facility Assessment and Protocols
-Resident Assessment and Monitoring Tools
-Prevention Tools
-Treatment Tools
-Communication Among Providers
These tools may also be downloaded separately. This packet contains all of the tools on this webpage marked with the PUP logo except the PUP Resident and Family Brochure.

Guide to Prevent Pressure Ulcers

This How-to Guide describes key evidence-based care components for preventing pressure ulcers, describes how to implement these interventions, and recommends measures to gauge improvement. The guide was initially developed as part of IHI’s 5 Million Lives Campaign.

Medical Equipment Maintenance Guide

Safer E.H.R.’s: An Introduction to the SAFER Guides

CMS High Risk Medication List for Elderly

Quality ID #238 (NQF 0022): Use of High-Risk Medications in the Elderly
– National Quality Strategy Domain: Patient Safety
– Meaningful Measure Area: Medication Management


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.