OIG Report Calls For Improved Tracking Of Serious Adverse Events In Hospitals

MHA Staff Contact:  Sharon Burnett

A  report from the U.S. Department of Health and Human Services’ Office of Inspector General finds state survey agencies need to improve their tracking of serious hospital errors, including suicide and other adverse events. OIG recommends that the Centers for Medicare & Medicaid Services require all immediate jeopardy complaint surveys to evaluate compliance with the quality assessment and performance improvement Conditions of Participation. OIG also suggests that CMS ensure state agencies monitor hospitals’ corrective actions for sustained improvements, amend guidance on disclosure to explain the nature of complaints to hospitals and improve communication with accreditors.

CMS Releases New Tools and Launches Initiatives Linked to Patient Safety

CMS has released a new online tool to empower consumers to make informed choices about their health care. The Quality Care Finder links consumers with all of Medicare’s compare tools in one convenient location (www.Medicare.gov/QualityCareFinder). Also released is a revised Hospital Compare website with additional data related to outpatient surgical infections and heart attack care (www.hospitalcompare.hhs.gov).     Dr. Don Berwick, CMS Administrator, states “These tools are new ways CMS is making sure consumers have… important information they need to make the best decisions about where to receive high-quality care.”

Medicaid to Stop Paying for Preventable Events, Providers to Submit Claims Reports for Events

A newly published federal rule requires Medicaid programs to implement non-payment policies for preventable events by July 2012.

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MOCPS Participating in the Regional Symposium on Accountable Care Organizations

The Center will be attending the Regional Symposium on Accountable Care Organizations, Thursday, April 28th at the Tiffany Greens Golf Clubhouse in Kansas City.

The symposium is important because of the great presenters who will be sharing valuable updates, strategies and more.



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.