CPS Safety Watch/Alert: Contaminated Supply

PSOwatchIt has been reported to the Center for Patient Safety that some organizations have experienced sterile syringes and butterfly needles being contaminated within their sterile packaging.


  • Encourage staff to please be watchful of all sterile packages.
  • If the supplies/equipment are noted to be contaminated, they should not be utilized
  • Remind staff to file a report in your event reporting process to notify leadership
  • Leadership should follow up with the vendor

April is Missouri Patient Safety Awareness Month

April is Missouri Patient Safety Awareness Month, sponsored by the Missouri Center for Patient Safety (MOCPS) to maintain a focus on the importance of error prevention in health care. In recognition of health care professionals’ efforts to provide safe care 24 hours a day, 7 days a week, 365 days a year, the MOCPS has developed provider and consumer resources to promote awareness of the importance of patient safety

Jefferson City, Missouri (PRWEB) April 02, 2012

Jefferson City, Missouri – April 2, 2012 — April is Patient Safety Awareness Month (PSAM) in Missouri and the Missouri Center for Patient Safety (MOCPS), is recognizing the importance of safe health care 24 hours a day, 7 days a week, 365 days a year, by making available resources on safe care for consumers, and a Safety Promotion Toolkit for healthcare providers and professionals to promote their continuous focus on safe care. https://www.centerforpatientsafety.org/april-2012-missouri-patient-safety-awareness-month


Hospitals Can Offer AHRQ’s Free “Taking Care of Myself Brochure to Patients Being Discharged

In support of Patient Safety Awareness Week (March 4-10), the Agency for Healthcare Research and Quality (AHRQ) offers a bilingual guide that can help hospitals reduce their readmission rates by better preparing patients for self-care and follow-up appointments before they leave the hospital. The guide-Taking Care of Myself: A Guide for When I Leave the Hospital/Cómo cuidarme: Guía para cuando salga del hospital-is available as a printed document or fillable PDF that clinicians can complete in the hospital and share with patients before they leave. The guide is adapted from Project RED (Re-Engineered Discharge), which was funded by AHRQ and developed by Brian Jack, M.D., and colleagues at Boston University Medical Center. For a copy of the guide in English, go to:  http://www.ahrq.gov/qual/goinghomeguide.htm  or in Spanish, visit:  http://www.ahrq.gov/qual/goinghomesp.htm

To order print copies, email your request to  [email protected]  or call  800-358-9295.

For the brochure in English, please reference AHRQ No. 10-0059 with your request, or for the brochure in Spanish, please reference AHRQ Pub. No. 10-0059-C.


AHRQ’s Perspectives on Safety

Lawrence Smith, MD, founding dean of the Hofstra North Shore-LIJ School of Medicine, recently gave an  interview, on resident supervision and patient safety. Listen to an excerpt online or download a podcast. An accompanying  perspective piece, by C. Jessica Dine, MD, MA, and Jennifer S. Myers, MD, University of Pennsylvania, examine how increased supervision influences the educational experience for trainees.


Tips for a Successful Survey on Patient Safety Culture

The Hospital Survey on Patient Safety Culture is an invaluable diagnostic tool that allows you to look beyond the physical impression of your facility’s culture. AHRQ’s in-depth study of question formatting, wording, and categorizing has resulted in a highly reliable resource that can provide a detailed analysis of your patient safety culture. The results will provide supporting evidence of positive cultural improvements and locate areas of cultural weaknesses.   AHRQ offers a national database so you can see how you measure up:   Check out the 2012 Comparative Database Report!

But all too often, surveys are distributed, results are collected, and then… nothing happens.   (more…)

ASHRM Webinar – Have a Heart: Caring for our Own

Tuesday, February 14, 2012, 1 – 2 p.m.   CT Will provide insights into the second victim experience, interventions for supporting colleagues in distress and lessons learned from the University of Missouri.

With Guest Speaker, Susan Scott, RN, MSN

When a patient suffers from an unexpected clinical event, healthcare clinicians often become the “second victim,” feel as though they have failed the patient and frequently second guessing their clinical skills, knowledge base and career choice.

Understanding the second victim experience and recognizing that supportive interventions can promote a healthy recovery during this vulnerable period is critical.

Guest Speaker, Susan Scott, serves as Patient Safety Officer for University of Missouri Health Care. With more than 30 years of nursing experience, Scott’s Patient Safety research include understanding the second victim phenomenon to help interdisciplinary professionals in the aftermath of unanticipated clinical outcomes.

Register Now!


Primaris Taps the MOCPS to Lead CUSP Training Program

MOCPS is pleased to announce that Primaris, the federally designated Quality Improvement Organization (QIO) for the state of Missouri, has asked us to lead the Basics of Comprehensive Unit-based Safety Program (CUSP) training program for seven hospitals as part of a CAUTI training project.  We are honored that Primaris has recognized our expertise with CUSP and success in working with hospitals to implement it successfully.  The Basics of CUSP is part of the Center’s People, Priorities and Learning Together initiative.

The Q4 Issue of the Forum Newsletter is Now Online

Check out the last issue of ASHRM’s Forum newsletter for 2011. The Q4 issue profiles ASHRM President-Elect Mary Anne Hilliard and her goal to “get to zero” serious safety events. Part two of the electronics medical records (EMRs) article (continued from Q3) looks at the advantages and pitfalls of EMRs. The patient safety article shines a light on the most overlooked victims of adverse events-healthcare workers. As always, the Forum details ASHRM’s latest accomplishments and lists the newest CPHRMs.

Joint Commission Releases New Sentinel Event Alert on Long Work Hours

The Joint Commission is warning hospitals about the potential dangers of extended hours and excessive workloads in a new Sentinel Event Alert. The alert contains documented links between healthcare worker fatigue and adverse events, as well as lower productivity. Sleep deprivation or lack of quality sleep over an extended amount of time can lead to confusion, irritability, memory lapses, loss of empathy, and compromised problem-solving, among other things, according to the Alert. The Joint Commission suggests organizations assess their fatigue-related risks, including off-shift hours and consecutive shift work; examine the hand-off process; invite staff to offer input in their own work schedules; implement a fatigue management plan; and educate staff about the effects of fatigue on patient safety.

CPS Safety Watch/Alert: Fatigue Impacts Patient Safety

The link between health care worker fatigue and patient safety is not unfamiliar. But have you assessed your organization to mitigate health-care worker fatigue-related risks? The Joint Commission suggests the following: a review of the work shift schedule with staff involvement; an assessment of high-risk processes and procedures (such as patient hand-offs); education on sleep hygiene (getting enough sleep and practicing good sleep habits that can impact sleep); and promotion of a safe culture through open communication about fatigue concerns as well as a focus on teamwork to support staff working extended hours. The result of these efforts can protect your patients from harm.

Read more about what you can do in Issue 48 of the The Joint Commission Sentinel Event Alert.

For more information, check out our links to several Communication & Teamwork Toolkits!

Interested in finding out what your safety culture is? Check out the Survey on Patient Safety Culture!


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.