Welcome to the Patient Safety Resource Catalog!

dhughesDo it for Drew Hear Drew’s story. A patient’s story provides a powerful message worth sharing, and Drew’s story is no different… Thirteen-year-old Drew was intubated as a precaution for transport to a larger hospital. During the transport, several things went wrong, one being Drew’s tube was placed in his esophagus instead of his trachea, depriving him of oxygen for 30 minutes and resulting in his death. UNDERSTAND THE MESSAGE This webinar will focus on the story of Drew Hughes, who died from an anoxic injury due to an esophageal intubation during an interfacility transfer.  Hear from Drew’s father and find out how this tragedy happened – and learn how it could have been prevented.  Additionally, learn why developing and nurturing a culture of patient safety is such an important part of healthcare today. CPS AND “DO IT FOR DREW” The Center for Patient Safety supports the sharing of Drew’s story to promote awareness and support patient safety improvements. David Hughes, Drew’s father, leads a foundation to raise awareness about patient safety and the importance of airway management.

Clinical Topics

Patient Safety Organization (PSO)

Patient Safety Culture

Alerts and Watches


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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.