AHRQ Trigger Tool

AHRQ has published a new trigger tool that identifies harms due to hospital care among children.  The tool uses electronic or written data to retrospectively identify adverse events in pediatric patients. “This tool will help doctors and other practitioners caring for children to develop safer practices,” said AHRQ Director Andy Bindman, M.D. “A reliable trigger tool will help clinicians recognize potential safety concerns quickly from routine information collected from the medical record. Making providers aware of this information will help them avoid similar mistakes in the future.”

Tool is available here.


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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