Hospitals face fines for overdose, leaving sponge in patient

L.A. NOW – Southern California

The California Department of Public Health issued $850,000 in fines against 14 hospitals for medical errors that caused – or were likely to cause – serious injury or death to patients, officials announced Thursday.

Three of the hospitals – Henry Mayo Newhall Memorial Hospital, Los Angeles County-USC Medical Center and Torrance Memorial Medical Center – were in Los Angeles County.

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Latest Issue of AHRQ WebM&M

This month, the Perspectives on Safety section covers fall prevention with Ann L. Hendrich, RN, PhD, of Ascension Health. A leading expert on health care-associated falls, who developed one of the most widely used risk assessment tools. Listen to an excerpt online or download a podcast interview.

In the Spotlight Case, “Order Interrupted by Text: Multitasking Mishap,” while entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and forgot to complete the order.

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Latest AHRQ Newsletter Notes Improved Patient Safety with Medical Team Training

The November AHRQ newsletter has two examples about the positive influence of team training on medical workers and its effect on patient safety.     Dr. Robert Wachter, Editor of AHRQ WebM&M, spoke with Dr. Eduardo Salas, a professor of Psychology at the University of Central Florida who served in the Navy for 15 years, about applying lessons learned from military team work training to medical teams.   “Those who know about teamwork do better.” Read the  interview and listen to a perspective piece online.

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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.

Chicagoland Patient Safety Summit: Focus on Transparency

Kimberly O’Brien shares a recent experience: The 2011 Chicagoland Patient Safety Summit kicked off on September 15th with a heartbreaking story from an Indiana family who recently lost Michelle – their beloved daughter, sister, wife and mother – to a medical error at a Chicago-based hospital. There wasn’t a dry eye in the room of over 150 providers and other patient safety advocates as Michelle’s family recounted the painful details of the days and hours leading up to Michelle’s premature and preventable death.

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MOCPS Hosts Table at Health Literacy Missouri – Sorrel King reinforces our mission

The MOCPS was pleased to host a table at the October 5th Health Literacy Missouri awards luncheon.   Keynote, Sorrel King, is always a pleasure to hear, although the story of her 18 month old daughter, Josie’s, death from failures in the health care system is heart wrenching.   (more…)

13 Missouri Hospitals Target Increased Patient Safety with the Missouri Center for Patient Safety’s CUSP Teamwork & Communications Tools

Effective new strategies rally hospital unit team members to improve patient care and safety with a new level of practical collaboration citing “What you permit, you promote.”

Jefferson City, Missouri – July 21, 2011 — As part of the Missouri Center for Patient Safety’s initiative, People, Priorities & Learning Together, 13 Missouri hospitals have joined CUSP Teamwork & Communication Tools, launched in June, 2011, to increase patient safety and eliminate medical errors by improving communication and coordination of care at the bedside.

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Toolkit to Help Caregivers Involved in Medical Errors

MITSS has developed a toolkit, with assistance of experts, including University HealthCare’s Sue Scott based on their work with the Second Victim, to help caregivers involved with medical errors.

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Patients and Caregivers are Victims of Medical Error

Kimberly Hiatt, a nurse involved in a medical error that resulted in the death of an 8 month old, committed suicide.   This important story highlights the many victims of medical error, the importance of a just culture, and the need for resources to help the second victim.

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MOCPS Celebrates Five Years!

For five years, the Missouri Center for Patient Safety has worked for health care change by bringing organizations and individuals together to improve patient safety.     The goal: learn as much as possible about medical errors, so we can prevent them from occurring.

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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.