Hospitals & ASCs

It’s been over 15 years since the Institute of Medicine (IOM) issued its first report, “To Err is Human,” providing a comprehensive strategy for healthcare providers, the government, payors, and consumers to reduce medical errors by fifty percent. We all know that goal has not been achieved. Medical errors resulting in patient harm and even death continue to occur daily across our nation.

On the positive side, many leaders have committed to patient safety improvement by making it a key strategic imperative and deploying more reliable processes to diminish the chances of errors and harm. There have been pockets of improvement in areas such as central line associated blood stream infections, surgical site infections and catheter-associated urinary-tract infections. While we celebrate these successes, we must all re-pledge our commitment to make greater and faster progress to fill the existing gaps. We have learned that despite our best efforts, errors will occur because we are human. The goal, then, is to design safer care systems so harm does not reach the patient.

The Center for Patient Safety is committed to promoting safe and quality healthcare, helping providers design safer processes and systems to reduce medical errors. Driven by the vision of a healthcare environment safe for all patients and healthcare providers, in all processes all the time, the Center serves as a central resource and facilitator to improve the safety and quality of care provided to citizens using a collaborative approach to education, information, resource sharing and learning.

You may have heard the saying that “culture eats strategy for lunch,” meaning a culture that embraces patient safety is a foundational requirement for safe care. The Center emphasizes the importance of culture in promoting safe systems of care, which support individualized care, teamwork and communication. In 2015 the Center completed 35,000 patient safety surveys for 39 organizations. Organizations have commented on the value of the detailed feedback report: “We love the Center’s patient safety culture survey feedback reports. The department level reports give a level of granularity we were lacking with previous surveys.”

One of the Center’s major tools to identify opportunities for improvement is the PSO database where the participants share events, near misses, unsafe conditions and lessons learned through root cause analyses. The database grew 55% from 2014 to over 44,000 reports in 2015. Analysis of the data lead to distribution of safety watches or alerts for topics such as scope sterilization and prevention of violent behavior as well as numerous safety suggestions shared in the quarterly PSO Newsletter. Adding options of electronic data submission in 2015 has resulted in easier submission and has been well received by PSO participants.

The Center continues to focus on three objectives:

  1. Protecting – personal guidance on how to best protect patient safety and quality analysis and deliberations
  2. Learning – new opportunities to improve patient safety culture and implement best practices
  3. Preventing – improve culture to reduce adverse events and patient harm

The Center values all providers and looks forward to a long future as partners to improve patient safety for all individuals.

The Center for Patient Safety (CPS) offers several patient safety services specific to hospitals and ambulatory surgery centers:

PSO Services:
PSO Services

Culture Services:
Survey on Patient Safety Culture
Comprehensive Unit-based Safety Program
Just Culture
Second Victim Experience

Learn More:
Hospitals & ASCs working with CPS


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.