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.

Recommendations:

  • 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

CPS Safety Watch/Alert: Endotracheal Intubation in EMS

Safety WatchThe Center for Patient Safety is issuing a Safety Watch based on industry data and recent findings from event data being submitted to the PSO.  The following areas of concern have been reported to the PSO:

  • Tube dislodgement during patient movement
  • Patient aspiration
  • Rapid Sequence Intubation

BLOG:

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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RESOURCES:

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.