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.


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.


MRI Safety Week, Getting to the Root Cause and Prevention

MRI Safety Week (this past June) was founded to celebrate and promote excellence in MRI safety. Much of the week long event was inspired by the 2001 tragic MRI-related death of Michael Columbini, age 6, resulting from a portable steel oxygen cylinder being brought into the MRI room during his exam.

Even though this MRI safety week information came to us this summer, activity surrounding the related resources continues on LinkedIn.   It’s great info showing how analysis at the root cause level is needed and what can be gained.


MOCPS 6th Annual Conference Line Up for “Conquering Chaos – the Humanity and Science of Safe Care”, April 17, 2012

We’re excited to announce our agenda for our 6th Annual Conference, titled “Conquering Chaos – the Humanity and Science of Safe Care.”   Keynoting is a courageous health care team from St. Johns in Joplin, Missouri, sharing their insights on how they ensured the safety of patients and staff during the EF-5 tornado of May, 2011.   Visit our conference web page for more information. (more…)

Streamline Your Patient Safety Culture Survey!

Do you Want to Streamline your Patient Safety Culture Survey?

Using AHRQ’s standardized test questions and format, the Missouri Center for Patient Safety has developed a convenient, online environment for your staff to anonymously take the survey on a computer at work, at home, or in the local coffee shop – anywhere they feel comfortable providing honest feedback about your safety culture.


MOCPS Issues Call for Missouri Excellence in Safe Care Award Applications!

The MOCPS announces its fourth call for applicants for the Missouri Excellence in Safe Care Award.   Applications for award consideration are due to MOCPS no later than December 30, 2011.   Visit our conference web page for more information.



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.


Surgical Fire Prevention Toolkit from the FDA

The Food and Drug Administration has launched the Preventing Surgical Fires Initiative.   Resources that are part of the initiative include a toolkit for organizations to use to reduce the risk of surgical fires including a fire safety video from the Anesthesia Patient Safety Foundation.   As part of the initiative, the Association of PeriOperative Registered Nurses is making the Fire Safety Toolkit available for download free of charge through November 13.  

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…)

MOCPS Speakers Bureau Unveiled!

Announcing the Missouri Center for Patient Safety’s Health Care Speakers Bureau!

The MOCPS Patient Safety Speakers Bureau was formed as a resource for patient safety related conferences, seminars or meetings sponsored or hosted by your agency, association or organization.   Our veteran speakers offer their expertise on Patient Safety, Just Culture, Transparency, Disclosure, Healthcare Acquired Infections, Reimbursement, Health Care Reform 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.