PSO

PSO
THE CENTER FOR PATIENT SAFETY
NEWS
SUMMER 2016 NEWSLETTER
MEETING OF
THE MINDS
CPS' ANNUAL PATIENT SAFETY CONFERENCE BRINGS
TOGETHER EXPERTS FROM ACROSS THE COUNTRY
WITH A SINGULAR GOAL: ELIMINATE HARM.

MAKING THE ROUNDS | IN THIS EDITION
ON THE COVER:
LEARNING
OPPORTUNITIES
Just culture, keynote speakers
among the highlights as this
year's PSO Day and Patient
Safety Conference bring
together attendees from
across the nation, all who have the
same goal in mind: eliminate
patient harm! 12
ALSO INSIDE:
A NEED FOR SPEED
Improving Event Investigation through
the Development of SPRINT: Serious
Patient Safety Event Rapid Investigation
Teams. 4
THE ORANGE DOOR
Facing use of street drugs and alcohol,
and decreased availability of medical
care and facilities for individuals suffering
mental or behavioral illnesses, Liberty
Hospital has been able to stem the tide
using a multi-disciplinary approach to
helping create a safer care environment
for staff and patients alike. 6
8TH ANNUAL AHRQ PSO
MEETING
What the AHRQ guidance
means for providers and their
patients. 11
PSO LEGAL UPDATE:
Cases involving the
Patient Safety and Quality
Improvement Act continue to
work their way through state
and federal courts. 15
EMS UPDATE:
New CPS report seeks
to raise awareness of
safety concerns in the EMS
community. 16
ALSO IN THIS ISSUE:
SAFETY INSIDER 9
PSO UPDATE 18
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PSONEWS SUMMER SPRING 2016
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY

CALL TO ACTION | REPORT HIGHLIGHTS NEED FOR CHANGE
CALL TO ACTION:
CHANGE THE STATISTIC
AN ARTICLE RELEASED IN MAY FROM BMJ INDICATES MEDICAL ERRORS
ARE THE THIRD LEADING CAUSE OF DEATH IN HEALTHCARE IN THE UNITED
STATES AFTER HEART DISEASE AND CANCER. CALL TO ACTION RECOMMENDS
CULTURE IMPROVEMENTS.
BY ALEX CHRISTGEN, BS, CPPS
Center for Patient Safety
The article follows the 1999 IOM report which made the first attempt to determine preventable harm
in healthcare. The IOM report estimated a staggering 44,000 to 98,000 patient deaths each year due to
medical errors. In 2013, the IOM's reported numbers were determined to be grossly underestimated
based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per
year as result of medical errors.
In 2013, the IOM's reported numbers were determined to be
grossly underestimated based on a newer study suggesting the
actual number was likely to be more than 400,000 deaths per
year as result of medical errors.
Although the BMJ article specifically references medical
errors in the inpatient hospital setting, CPS’ recently released
annual report suggests medical errors in LTC, home care, and
EMS settings may be just as prevalent.
The following call to action is recommended:
1. make errors more visible when they occur so their
effects can be intercepted
2. have remedies at hand to rescue patients
3. make errors less frequent by following principles that
take human limitations into account
This Call to Action aligns with the recent IOM update in 2015,
which lists eight recommendations for improving patient safety,
and specifically diagnostic errors, in healthcare. Two of the
eight recommendations call for:
1. an enhanced focus on a culture that supports the open
discussion of errors
2. a collaboration of patient safety across the continuum
of care through organizations, such as a Patient Safety
Organization (PSO), that support safe sharing and
learning.
The Center for Patient Safety (CPS) has recognized these
areas as strategic approaches to reduce harm for quite some
time. We’ve embedded supportive culture improvement
programs (Just Culture, CUSP, TeamSTEPPS, Second Victims
Programs, and culture assessments) and offer safe sharing
opportunities (as a PSO) that support CPS’ vision of improving
patient safety for all patients and healthcare providers, in all
processes, all the time.
Through our program objectives of Protecting, Learning,
and Preventing, CPS is currently working with hundreds of
organizations and thousands of healthcare providers in 38
states across the country to improve patient safety every day.
Together, we will reduce preventable harm in healthcare.
Contact me if you have questions about any of the recently
released reports or if you would like to talk about what you can
do to join the healthcare movement to safer care.
ALEX CHRISTGEN is the interim Executive Director for the
Center for Patient Safety. You can reach her at achristgen@
centerforpatientsafety.org.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016
3

A NEED FOR SPEED
IMPROVEMENT OF EVENT INVESTIGATION THROUGH THE DEVELOPMENT
OF SPRINT: SERIOUS PATIENT SAFETY EVENT RAPID INVESTIGATION TEAM
BY BECKY DOERHOFF, RN, MSN, CNL
& MICHAEL LANE, MD, MPHS, CPPS
BJC Healthcare
The Joint Commission (TJC) adopted a formal Sentinel Event Policy in 1996 to help promote careful
investigation and analysis of patient safety events as well as to encourage effective corrective actions
to prevent future events. Accredited institutions are expected to identify and respond appropriately to
all sentinel events (such as unintended retained foreign items) and are subject to review by The Joint
Commission.1
The pioneering efforts initiated by TJC attempted to set the framework for healthcare investigators to take a
systems-based approach to event analysis. This initiative alone has been not been sufficient in preventing events
of harm that occur every year. In a study released this spring from Johns Hopkins, it is suggested that medical error
be considered the 3rd leading cause of death in the CDC ranking of most common causes of death, which would
translate to roughly 400,000 lives.2
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Foundational to the SPRINT process is the application of
Just Culture, which ensures justice in response to human
error and behavioral choices. High Reliability and Human
Factors Engineering principles were also integrated into the
process. A few of the standard process tools utilized by the
team include: causal diagrams, timelines, process maps,
diagrams and payoff matrix for proposed interventions.
Weekly calls, using a standard agenda template, occur to
discuss new and ongoing events with all the Patient Safety
and Risk Managers across the system. Event action plans are
discussed at the system Risk and Patient Safety Council and
selected interventions are rated for strength of action based
on Human Factors Engineering principles.
In 2014, representatives from Risk and
Patient Safety across the BJC Health Service
Organizations (HSOs) began to design
and pilot a core team that could assist in
the analysis, action plan development and
the dissemination of learning from serious
patient safety events (SPSEs)* throughout
the system. The vision of the process was
to have ‘a cadre of well-trained, highly respected
expert investigators guiding local
investigations...’ that would reinforce the
values of the organization and provide a
standard and robust investigation lifecycle.
The process was inspired by several investigative
methods, such as, The London
Protocol, James Reason Model of Accident
Causation, RCA2: Improving Root Cause
Analyses and Actions to Prevent Harm.
The team was named ‘SPRINT’ and
launched with Patient Safety Specialists
from the system level and volunteers from
three other facilities, representing community,
academic and alternate sites. During
the pilot phase roughly 20 events were
investigated over 6 months using the new
process. The team was composed of a HSO
lead, a SPRINT lead, key HSO leadership,
staff or subject matter experts and physicians.
SPSE and close call events that had a
high likelihood of harm if a barrier had not
been in place were in scope for the pilot.
See content above for more information
on process components and event action
plans.
Investigations during the pilot phase
were more robust and resulted in stronger
action items. A rapid improvement event
was held to further enhance the process.
Resource allocation was deemed essential
for ongoing success and to ensure that
appropriately trained, dedicated facilitators
for event investigation were available
to achieve consistent and reliable results.
The 2nd phase was launched in the fall
of 2015. Process Improvement Engineers
were added to the team composition to
expand the expertise and independent assessment
of the process. Automatic action
plan check-in’s were added at 6 months
and 1 year to aid in identifying barriers that
were not predicted when initially planning
for stronger more entailed interventions.
Weekly updates of events are communicated
to the system executive team. The
executive team receives a quarterly update
with process metrics and themes.
SPRINT continues to evolve and refine
over time. Areas of focus for improvement
include: disseminating pertinent information
to frontline staff, providing consistent
clinician support by trained experts in a
systematic way and incorporating proactive
risk assessment into the process.
BECKY DOERHOFF is the Manager for
Patient Safety for the Center of Clinical
Excellence at BJC Healthcare. You can reach
her at rjdoerhoff@bjc.org.
MICHAEL LANE is an Outcomes Physician
at the Center of Clinical Excellence at BJC
Healthcare and Assistant Professor of
Medicine, Division of Infectious Diseases at
Washington University School of Medicine.
You can reach him at michael.lane1@bjc.
org.
REFERENCES:
1.
The Joint Commission. Sentinel Event Policy and Procedures. https://www.jointcommission.org/sentinel_event_policy_and_
procedures/. Published January 6th, 2016. Accessed May 10th, 2016.
2.
Makary, Martin & Daniel, Michael. Medical error-the third leading cause of death in the US. BMJ. http://www.bmj.com/content/
bmj/353/bmj.i2139.full.pdf. Published May 3rd, 2016. Accessed May 10th, 2016.
* SPSEs are events in medical care that are clearly identifiable, preventable, and resulted in severe temporary harm, permanent
harm or death. Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent
residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for
a life-threatening condition or additional major surgery, procedure, or treatment to resolve the condition. In contrast, some events,
although serious and adverse, relate to a patient’s underlying medical condition. Preventability implies that methods for averting
a given injury are established and that an adverse event results from failures to apply that knowledge. SPSEs include those events
deemed preventable upon review and defined by the Joint Commission as reportable and reviewable Sentinel Events, National
Quality Forum (NQF) Serious Reportable Events in Healthcare.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016
5

THE ORANGE DOOR
BY JOANIE PETERSON, RN, JD
Liberty Hospital
It’s been more than four years since Liberty Hospital, a 233-bed medical center north of Kansas City, began
its “Orange Door” program. With the increased use of street drugs and alcohol, and decreased availability
of medical care and facilities for individuals suffering mental or behavioral illnesses, patient violent behavior
was getting out of control. Unfortunately, in the past, healthcare providers traditionally accepted violent
behavior as “part of the job” and were reluctant to speak up or report incidents. This culture presented an unsafe
environment for staff, patients and visitors.
TAKING ACTION - CODE WHITE
In 2012 Liberty Hospital took action to address this growing
challenge. They partnered with the “Handle with Care” (HWC)
Behavior Management program to provide de-escalation training
for all patient care staff. A small multi-disciplinary team revisited
their process for getting additional security personnel to the scene
of the disruptive behavior. The team realized that sometimes a
person in uniform can escalate tension rather than de-escalate.
It also was determined that a “show of force/support” can deter
some from becoming aggressive when faced with more than one
staff member. A multi-disciplinary approach was identified for this
process instead of just using security officers. “Code White” was
developed, which alerts the crisis intervention response team that
additional assistance is needed to handle a violent patient, family
member or visitor. View Code White Policy - CPS PSO participants
only
THE “ORANGE DOOR”
Staff needed a way to identify patients as imminent risk to self
or others. Clear communication to identify which patients are at
risk is addressed by the “Orange Door”, which includes:
• A placard placed on the door of any patient at risk for violent
behavior to self or others;
• Revision of the communication board at the nursing stations
so the patient’s name is highlighted in light orange for all staff to
be alerted of potential violence;
• Additional training for staff to understand and identify suicide-imminent
risk to self and others
• Communication with the patient, family members and/or visitors
regarding expectations as defined in the Suicide: Imminent
Risk to Self or Others policy. View Policy - CPS PSO participants
only; and
• Constant Observation program - Training and brochures for
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Liberty Hospital is a 250-bed facility in Liberty, Mo.
the staff member who is sitting with the patient and one for the
patient and their families on what to expect while under Constant
Observation.
IT TAKES A VILLAGE
Education is key for the success of this program. All staff have
three hours of de-escalation training at orientation. Patient care
and other identified staff members are recertified every 2 years.
The ED, ICU, Nursing Supervisors, Social Services, and Code White
(Critical Incident Response Team) staff members take a full eighthour
training in addition to the three-hour education and again
are recertified every 2 years. In-house instructors for Handle With
Care are recertified every year. The hospital works closely with local
law enforcement agencies, fire departments, and EMS services,
educating on what happens when a non-medical patient with violent
behavior is brought to Liberty Hospital’s ED. Since Liberty
has no behavioral medicine beds, the patient must be assessed
in the ED and be held until staff can arrange a safe transfer to a
facility that provides mental healthcare. These first responders are
taught how to identify the need for behavioral care in the field so
patients can be taken to the appropriate facilities whenever possible.
When known behavioral health/violent patients are brought
WORKMAN'S COMP COSTS
DUE TO VIOLENT BEHAVIOR
YEAR: COST: INJURIES:
2014 $57,000 3
2015 11,000 1
2016 0 0
CODE WHITE CALL RESOLUTIONS
BY VERBAL DEESCALATION
YEAR:
DEESCALATIONS:
2014 80
2015 65
2016 17
to the ED, they are admitted to a “safe room”, when available. This
room (located just inside the ambulance bay foyer) has been designed
specially with a small “garage door” that can be activated
to come down to cover medical equipment/gas connections. In
the remote situation where the door needs to be closed to help
with de-escalation, there also is a computer that can monitor the
patient via camera, allowing staff to remain safe and keep a constant
visual of the patient during the de-escalation process. The
adjoining bathroom is specially equipped with metal fixtures that
deter any attempts at self-harm or destruction of property. The
patient can de-escalate in a safe environment and staff members
are able to assist without excess equipment that could get in the
way if restraint becomes necessary in the therapeutic process.
Recently “Orange Door” visitor lockers were installed on each of
the patient care units to ensure safe keeping of visitors’ belongings
and to keep dangerous items out of the patient rooms. In a recent
situation, a visitor was thankful the hospital provided lockers for her
to store her items, which assisted in loss prevention or damage.
Another wife was grateful that no one had been hurt when her
husband became aggressive, swinging and kicking, and told Josh
Stewart (a certified instructor and member of the critical incident
response team) she had never been anywhere where she felt she
had more assistance with her husband and said it was great.
THE RESULTS
Liberty Hospital has seen solid results from the “Orange Door”
program.
Many times staff don’t feel they need to call for a Code White
because they are able to verbally de-escalate the situation before
it becomes violent.
Changing the hospital’s approach to managing aggressive behavior
is difficult because it requires a change in mindset that any
patient can pose a risk. Caregivers are trained to give care, not to
think of patients as potential risk for aggressive behavior, violence
and harm. Liberty Hospital continues to change that mindset as
the bedside caregivers, medical staff members and first responders
work together to mitigate the risks of this issue.
FOR MORE INFORMATION on implementing the Orange Door
process, contact Joanie Peterson. You can reach her at Joanie.
Peterson@libertyhospital.org.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016 2016
7

The Center for Patient Safety,
in collaboration with the University
of Missouri Health System’s Second
Victim Program is pleased to host
the following workshop...
SECOND VICTIM
TRAIN-THE-TRAINER
WORKSHOP
The Center for Patient Safety, in
collaboration with the University of Missouri
Health System’s Second Victim Program is
pleased to host the following workshop:
Date: November 7
Time: 7:30 a.m. to 3 p.m.
Location: Saint Luke’s North Hospital –
Barry Road, 5830 Northwest Barry Road,
Kansas City, MO 64154, located just 10
minutes from the Kansas City International
Airport (MCI).
Cost: $399 per person ($349 for
each additional person from the same
organization)
Registration: https://www.eventbrite.
com/e/second-victim-train-the-trainerworkshop-registration-20923246995
“Healthcare team members involved in an unanticipated patient event,
a medical error and/or a patient related injury can become victimized in
the sense that they are traumatized by the event. Frequently, these
individuals feel personally responsible for the patient outcome.
Many feel as though they have failed the patient, second
guessing their clinical skills and knowledge base.”
Who can benefit:
When patients suffer an unexpected clinical event, healthcare clinicians involved in the care may
also be impacted and are at risk of suffering as a “second victim”. Understanding this experience and
recognizing the need for supportive interventions is critically important. This workshop will provide
insights into the experience as well as interventions of support. This workshop will also provide
instruction so that each participant will return to their organization with the knowledge, skills, and
techniques necessary to support and train their peers.
PRESENTED BY THE CENTER FOR PATIENT
SAFETY AND THE UNIVERSITY OF MISSOURI
HEALTH SYSTEM’S SECOND VICTIM PROGRAM
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CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY

PATIENT SAFETY INSIDER | NEWS YOU CAN USE
CHECKLISTS, CHANGES BRING
TRANSFORMATIONS TO THE
PATIENT SAFETY COMMUNITY
“The best bet right now for organizations to support learning is to be part of a PSO. PSOs represent
a learning community. I urge PSOs to be open and generous with their work and share
great stuff.” Dr. Donald Berwick, past president of IHI
SAFETY CHECKLISTS
The American Hospital Association’s
Hospital Engagement Network (HRET)
has published 16 safety checklists to
eliminate patient harm. The checklists
are developed from evidence-based best
practices and include improvement strategies,
action items and resources that
may be effective within your organization.
Use each checklist to assess your
organization to identify your opportunities
for improvement.
RECOMMENDATIONS
FROM THE NPSF
Last year the National Patient Safety
Foundation convened an expert panel to
assess the state of patient safety across
the nation and set the stage for the next
15 years. Their focus is on the establishment
of a total systems approach
resulting in an improved culture of safety.
Government, regulators, health professionals,
and others are called to place
higher priority on patient safety science
and implementation by following these
eight recommendations:
1. Ensure that leaders establish and
sustain a safety culture
2. Create centralized and coordinated
oversight of patient safety
3. Create a common set of safety metrics
that reflect meaningful outcomes
4. Increase funding for research in
patient safety and implementation
science
5. Address safety across the entire
care continuum
6. Support the health care workforce
7. Partner with patients and families
for the safest care
8. Ensure that technology is safe and
optimized to improve patient safety
Read the full report here.
PSO HOLDS VALUE
FOR LONG TERM CARE
Do you have an affiliation with a longterm
care facility (LTC)? The value of participating
in a PSO is spreading across the
continuum of care. CPS has historically
offered PSO services to hospitals, medical
clinics, ambulatory surgery centers and
emergency medical services. However,
LTC providers may now join the PSO.
Many are already taking advantage of
Just Culture training and measuring their
culture with the safety culture survey.
For further information, contact Kathy
Wire, kwire@centerforpatientsafety.org.
CPS RELEASES ITS
2015 ANNUAL REPORT
The Center’s 2015 Annual PSO Report
was released earlier this year and contains
information on the data received
through the PSO. More than 45,000
events are summarized in the report.
If you have not already reviewed the
report, we encourage you to download
it here.
HOW TO AVOID DEADLY
INFECTIONS ASSOCIATED
WITH ENDOSCOPES
Many hospitals across the US are dealing
with infections caused by inappropriate
duodenoscope reprocessing. Don’t
be one of them! The Center for Patient
Safety partnered with the North Carolina
Quality Center PSO in April to sponsor
a webinar addressing the issue. CPS
PSO participants heard from Dr. William
Rutala, Director of Epidemiology at the
University of North Carolina Health, as
he explains the breadth of the challenge,
alternatives to scope processing and how
to prevent future infections.
PROMOTING SAFETY
WITH LEUR CONNECTORS
Historically, the Luer connector was
used for many incompatible purposes:
intravenous infusions, epidural catheters,
enteral feedings, blood pressure cuffs,
etc. Misconnections have occurred with
catastrophic results. California law will
soon mandate that hospitals use mutually
incompatible connectors for three
purposes: intravenous, neuraxial (e.g.,
epidural), and enteral. While the law driving
the adoption deadline is in California,
hospitals throughout the world will be
making this change.
Dr. Rory Jaffe, Executive Director of
the California Hospital PSO, is actively
engaged in the ISO standards process and
device manufacturers’ rollout planning.
Hear the inside story, from one of the few
on the International Standards Working
Group involved in planning the deployment
of the new devices. Major changes
will occur in the supply chain and at
hospitals. Prepare your hospital for the
change, and understand some of the
potential pitfalls ahead.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SPRING 2016
9

8TH ANNUAL AHRQ PSO MEETING
The Agency for Healthcare Research and Quality is headquartered in Rockville, Maryland.
A UNITED FRONT
TO IMPROVE CARE
Center for Patient Safety (CPS) staff
Kathy Wire, Lee Varner and Eunice
Halverson joined other PSO representatives
from around the country at
the Agency for Healthcare Research
and Quality (AHRQ) Headquarters in
Rockville, Maryland, for the 8th Annual
AHRQ PSO Meeting in April. As one of
81 PSOs certified nationally, operating
within 28 states and District of Columbia,
CPS continues to be a leader in
PSO activity. CPS is:
• 1 of nine PSOs with more than
250 PSO contracts
• 1 of 67 PSOs receiving reports
• 1 of 23 PSOs with more than
10,000 reports
• 1 of 38 PSOs offering services in
all states
• 1 of 2 PSOs providing services to
EMS services
• 1 of 36 PSOs receiving reports in
all AHRQ defined safety categories
• 1 of 11 PSOs submitting data to
the national PSO database (PSOPPC)
ONLINE: To learn more about
the Agency for Healthcare Research
and Quality, visit their
website at ahrq.gov.
BY EUNICE HALVERSON, MA
Center for Patient Safety
• AHRQ and CMS representatives discussed
the regulations for Section 1311(h)
of the Affordable Care Act which were
released earlier this year. The Section requires
hospitals with more than 50 beds
to engage with either an AHRQ-certified
PSO or alternative evidence-based initiatives,
in order to be eligible to participate
in Health Insurance Exchanges. This regulation
is effective January 1, 2017. CMS
strongly encourages organizations to report
patient safety events using AHRQ’s
standardized common data formats.
• Nidhi Singh Shah, CMS, noted that
the AHRQ and CMS have “reached an
agreement in principle” regarding coordination
of PSO activity and protections and
needs of CMS state surveyors to ensure
regulatory compliance.
• David Hunt, MD, Medical Director
of the Office of the National Coordinator
(ONC), advised that the ONC Health IT
Committee continues to work with NQF
to “learn, improve and lead” in the patient
safety world. They are seeking to identify
HIGHLIGHTS OF THE MEETING
and prioritize IT patient safety measures.
• PSO legal updates were shared by
Andrea Timashenka of the Department
of Health and Human Services. Details of
current legal cases can be found on the
CPS website (click to review). A team
from Baptist Health in Florida described
how hospitals across the state have
worked with their state regulators and
agreed how documents in patient safety
evaluation systems will be addressed. Despite
Amendment 7 in Florida, hospitals
have been successful in protecting their
patient safety work product. Presenters
cautioned, however, that PSO participants
need to have well-defined policies and report
to their PSO in order to successfully
claim the federal protections of the Patient
Safety and Quality Improvement Act
of 2005 in court. If you need help updating
your PSO policy, contact Eunice Halverson.
• The AHRQ has provided, and will continue
to develop, resources to help providers
better understand PSOs and select
a PSO on its website at www.pso.ahrq.gov.
FOR MORE INFORMATION, or for assistance updating your PSO policy, contact Eunice
Halverson. You can reach her at ehalverson@centerforpatientsafety.org.
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AHRQ GUIDANCE | WHAT DOES IT MEAN TO ME?
INCREASING OUR
UNDERSTANDING
WHAT THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY’S GUIDANCE
MEANS FOR HEALTHCARE PROVIDERS AND THEIR PATIENTS.
BY KATHY WIRE, JD, MBA, CPHRM
Center for Patient Safety
Patient Safety Organizations (PSOs) and their participants have
struggled with interpreting the Patient Safety and Quality
Improvement Act (PSQIA) with respect to handling patient
safety work that may be necessary to satisfy mandatory
reporting or other operational requirements. In an effort to ease
anxiety and develop a common understanding, the Agency for Healthcare
Research and Quality (AHRQ) has issued a statement (“Guidance”) on the
interface of (1) PSO protection of Patient Safety Work Product (PSWP) and
(2) mandatory reporting and operational requirements. AHRQ’s statement
is available online (click here). Below are some highlights, based on the
questions CPS gets most often from its participants. CPS participants are
encouraged to contact the Center’s staff with questions.
• The PSQIA has always required that
PSO participants keep the information
required to satisfy mandatory reporting
requirements outside of the PSWP “protected”
space. The Guidance reinforces
that requirement. However, the PSQIA and
the Final Rule allow participants to gather
information inside the PSES until they
know whether it will need to be reported.
If outside reporting is required, then the
information gathered in the PSES that has
not yet been reported to the PSO can be
pulled back out, so that it can be used to
satisfy the outside reporting requirement.
The Guidance recognizes both this early
PSES protection and the opportunity to
pull information from the protected space
when necessary.
• Like the Final Rule, the Guidance emphasizes
that analysis that takes place in
the PSES cannot be “dropped out.” It must
remain as PSWP.
• If a participant has a known obligation
under state or federal law to report certain
information, the provider should plan on
developing it outside the PSES, as it cannot
be PSWP.
• The Kentucky Supreme Court’s Tibbs
decision held that work surrounding mandatory
state reporting could not be protected,
as the state retained the right to
investigate how the provider was accomplishing
its reporting obligations. AHRQ’s
Guidance seems to question that position,
noting instead that information related
to the required reporting “form” could
be protected once the essential reporting
obligation has been fulfilled by submitting
the actual form, as long as the original documents
from which the report was developed
are still available.
• A variety of projects may take place
after a patient safety event. AHRQ’s Guidance
contains some helpful examples on
pages 6-7 of how that work can be viewed
as inside or outside of the PSES, and when
it will have to be non-PSWP because of
outside reporting requirements.
• AHRQ encourages PSOs and their participants
to work with state agencies and
regulators to determine what information
they need access to and what can reliably
be viewed as PSWP, so that there are fewer
confrontations on the front lines about
those issues. (NOTE: CPS has historically
supported its participants wherever possible.)
• The Guidance emphasizes that PSWP
is protected because it has been developed
for reporting to the PSO, and that the PSES
is a protected space for developing that
information. CPS has encouraged its participants
to view PSO reporting as the end
point of their PSES activities, and to actually
report to the PSO. AHRQ’s Guidance
underscores the importance of reporting.
• The Guidance specifically mentions
hospitals’ requirement under the Conditions
of Participation to track adverse
events, noting that there is a “legitimate
outside obligation” to keep those records.
42 CFR 482.21(a)(2) (https://www.law.
cornell.edu/cfr/text/42/482.21). Incident
reports have been a flashpoint in many
states with respect to surveyors’ ability to
see PSWP. PSO participants should carefully
consider what routinely reported
event information goes into or out of the
PSES. For example, some PSO advisors
recommend that basic incident data that
includes just patient name, date, location
and a brief description would allow regulators
to conduct their own investigations
while protecting the PSO participant’s
deeper investigation and analysis of those
events.
• The action plans or other actions or
changes that result from analysis inside the
PSES cannot be protected and can always
be shared with surveyors.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016
11

LEARNING
OPPORTUNITIES:
HIGHLIGHTS FROM THIS YEAR’S PSO DAY AND PATIENT SAFETY CONFERENCE
BY EUNICE HALVERSON, MA
Center for Patient Safety
Each year the Center for Patient Safety (CPS)
offers a PSO Day for its participants to meet
face-to-face to network and learn from each
other. This year’s Safe Table discussions on
April 6 centered around early identification of
sepsis and management of suicide ideation for patients
not on behavioral medicine units. One participant
noted, “I appreciate the opportunity to meet others
who often have the same challenges we face at our
hospital. I always look forward to learning from my
colleagues and determining what changes we can
implement to improve patient care, thus decreasing
the chances of future harm to our patients.” Safe
Table information is available to the Center’s PSO
participants. (CPS PSO Participants only)
SAFETY CONFERENCE
Over 140 health care professionals from several states gathered
at CPS’ 2016 Patient Safety conference in St. Louis on April 7.
Highlights included:
High Reliability - David Marx, the “father of Just Culture” and
well-known author and systems design engineer, provided insights
into “The Human Role in High Reliability”. Using his recent personal
experience of a family member’s hospitalization, Marx challenged
attendees to maximize human reliability by influencing the
design of the health care system and its processes. Throughout
the day, Marx spoke with attendees and autographed his newly
released book, “Dave’s Subs: A Novel Story about Workplace Accountability”,
a gift for each attendee.
Just Culture - Professionals from CoxHealth in Springfield, MO
shared their experience with the implementation of Just Culture
across their system. Vicki Good (Quality and Patient Safety), Mark
Alexander (Pre-hospital Services) and Cheryl Dunn (Employee Relations)
each explained the significance of their role in not only
implementing Just Culture but what they do to ensure it continues
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PSONEWS SPRING SUMMER 2016 2016
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY

POSTERS
Posters from ten organizations in six states
provided more opportunities for learning:
• Antibiotic Stewardship – Hannibal Regional
Healthcare System – Missouri
• Implement a Clinic-Centered Safety
Program – Mercy Clinic East Community –
Missouri
• Integrating an Institution-Wide Multidisciplinary
Safe Learning Environment to
Address Patient Safety Issues and Quality
Initiatives – VA Nebraska Western Iowa
Health Care System – Nebraska
• Medication Safety: Less Noise – Hannibal
Regional Healthcare System – Missouri
• Mitigating Preventable Adverse Events
with the Use of Safety Advisors – The Hospitals
of Providence Sierra Campus – Texas
• Novel Cutaneous Identification Device as
an Inpatient Identifier – Lenox Hill Hospital
– New York
• Population Health – Hannibal Regional
Healthcare System – Missouri
• Revitalizing the Traditional Hospital-Based
Root Cause Analysis with Lean Six Sigma –
Memorial Health System – Illinois
• Stay Standing: A Falls Prevention Collaboration
– Still University – Area Health
Education Center - Missouri
• Using Human Performance Tools to Reduce
Pediatric Medication Errors – University
of Michigan Health System – Michigan
to be “alive and well” at CoxHealth. Contact vicki.good@coxhealth.com for
more information.
Staff Empowerment – Jerry Reinke, representing the National Association
of Health Care Assistants, shared how improving relationships between
all caregivers, including nurse assistants, has a positive impact on direct patient
care.
Patient Safety Across the Continuum of Care – Michael Handler, MD,
Medical Director for CPS, as well as other Center staff challenged attendees
to consider patient safety concerns across the many settings of care: EMS,
ED, inpatient, surgery, ancillary departments, rehab, long-term care and
hospice. Ensuring complete and accurate communication, especially during
hand-offs of care, will help prevent errors which sometimes result in patient
harm.
Pediatric Errors in EMS – Peter Antevy, MD and EMS Medical Director
for several fire departments in southern Florida, explained how the human
brain contributes to human errors – and it can’t be avoided! He shared his
ongoing research to improve outcomes of pediatric arrests outside the hospital.
Many positive comments were received from PSO Day and conference
attendees, all who have the same goal in mind: eliminate patient harm!
FOR MORE INFORMATION on PSO Day or the Conference, email Eunice
Halverson at ehalverson@centerforpatientsafety.org.
“Don’t tell the Board how you messed up last month,
but rather tell them how you are preventing harm next
month. You can do this by completing RCAs on near
misses and measuring behavioral choices. Design good
systems to support good decisions. In the end, you will
help wonderful nurses be wonderfully safe nurses who
make good choices to be great caregivers.”
— David Marx, CEO, Outcome Engenuity
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016 2016
13

WATCH YOUR STEP!
BY TINA HILMAS, RN, BSN
Center for Patient Safety
For the past 3 years (2013, 2014 and 2015)
falls have remained in the top 5 reported
sentinel events. Despite the multitude of fall
prevention toolkits, healthcare organizations
continue to struggle with preventing falls.
There are many factors which contribute to falls
from balance to toileting activities to confusion to
medication. Medication as a contributing factor is
one of the more challenging factors to assess. While
medications such as anesthesia and pain medication
post-operatively automatically raise red flags, many
others do not.
In reviewing the data submitted to CPS, 146 falls were reportedly
associated with medication. Looking at the medications most
frequently cited:
1. Oxygen – 28 events
2. Pain medication/Anesthesia – 26 events
3. Blood thinners – 13 events
Oxygen is a major medication that automatically increases the
risk of falling. It is often overlooked because many times oxygen
is not considered a medication but rather a treatment. Many of
the events involving oxygen involved a patient not utilizing their
oxygen as prescribed. Oxygen deprivation can lead to confusion,
which can contribute to an unsteady balance and increase the risk
for falls. Also the oxygen tubing is a risk for a fall. It is important
to keep it out of the pathway of the patient utilizing the oxygen.
Pain medication and anesthesia post-operatively are also factors
that automatically increase a patient's risk for falling. While
this category automatically receives the most attention in regards
to increasing a person’s risk for falling, what isn’t always kept in
mind is the effect that anesthesia and medication have on the elderly.
Physiological changes that occur as a person ages also affect
how pain medications or anesthesia are metabolized by the elderly.
It can cause confusion, such as an elderly person who is no
longer weight bearing thinking they can stand. Age and post-op
status should automatically raise a patient’s risk factor for falling.
Patients who fall while taking blood thinners are at an increased
risk for harm. If these patients fall, the caregiver must always
consider whether an whether an intra-cranial hemorrhage
has occurred. Due to the dangerous potential consequences, this
patient population should always be considered high risk for falls
with appropriate precautions in place.
Be mindful if patients have any of these other medication factors:
1. Four or more medications
2. Anti-hypertensives such as Procardia
3. Antihistamines such as Benadryl or Atarax
4. Anti-platelets such as Persantine
5. Anti-depressants such as Elavil
6. Benzodiazepines such as Valium
7. Non-benzodiazepines such as Ambien or Lunesta
8. Cardiovascular agents such as Nifedipine
9. Insulin
In summary, when addressing falls, while many factors play a
part and can increase a patient's risk, one of the first areas to assess
for risk factors are the patient’s medications. It’s important
to evaluate not only the top 10% of the iceberg that is visible, but
also the 90% that is unseen that could truly help prevent a patient
from falling!
TINA HILMAS is a project manager at the Center for Patient Safety.
You can reach her at thilmas@centerforpatientsafety.org.
ONLINE: To access additional resources about preventing falls can be found on the following websites:
1. www.priorityhealth.com/provider/clinical-resources/ loads/2015/12/Collaborative-Assessment-Falls-in-Missouri.
medication-resources/~/media/documents/pharmacy/ pdf
cms-high-risk-medications.pdf
4. www.jointcommission.org/assets/1/18/SEA_55.pdf
2. www.drugguide.com/ddo/view/Davis-Drug-
5. www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf
Guide/109640/all/Drugs_Associated_with_Increased_Risk_
of_Falls_in_the_Elderly
6. www.centerfortransforminghealthcare.org/tst_pfi.aspx
3. www.centerforpatientsafety.org/wp-content/up-
7. psnet.ahrq.gov/resources/resource/29414
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CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY

LEGAL UPDATE | IMPACTING THE PATIENT SAFETY WORLD
FOUR PATIENT SAFETY CASES
WORK THROUGH COURTS
BY KATHY WIRE, JD, MBA, CPHRM
Center for Patient Safety
Cases involving the Patient Safety and Quality
Improvement Act continue to work their way
through state and federal courts with no major
changes.
Here is a status update on the significant cases:
1. Tibbs v. Bunnell (Kentucky)
The U.S. Supreme Court denied the hospital’s application for a
writ of certiorari (a request for the Court to review an issue that
relates to Federal law) filed in Tibbs v. Bunnell, No. 2012-SC-000603-
MR (Ky. Aug. 21, 2014). This means the Kentucky Supreme Court
decision will stand, in which the Kentucky Supreme Court ruled that
any work performed in order to meet State requirements could not
be patient safety work product, whether or not the work itself, or
other products of it, had to be reported. This decision, as it stands
now, applies only to Kentucky
2. Carron v. Newport Hospital (Rhode Island)
A plaintiff presented a Tibbs-type argument in Rhode Island. The
trial court simply entered an order requiring production of the protected
documents without any analysis. The case was appealed and
the state Supreme Court has agreed to hear it. This is good news,
in that the RI Supreme Court is interested in determining if the trial
court inaccurately overlooked the federal protection of the documents
declared by the defendant as patient safety work product.
3. Charles v. Southern Baptist Hospital (Florida)
The Florida Supreme Court has decided to accept the case on appeal.
A decision is expected this summer or fall. The (PSO-favorable)
appellate court decision rejected the Tibbs rationale. The trial court
had followed Tibbs and found that any document or other work
produced as part of compliance with a state requirement could not
be protected PSWP. The appellate court rejected that claim.
4. Baptist Richmond v. Agee (Kentucky)
This is an appeal before the Kentucky Supreme Court in which
the trial court ruled that the PSQIA protections only apply to information
being collected for the “sole purpose” of reporting to a
PSO. In other words, if being collected for any other purpose the
protections would not apply. The appellate court did not accept
the appeal, noting that this decision was consistent with the Tibbs
Kentucky Supreme Court ruling. This case is still being briefed and is
pending before the Kentucky Supreme Court.
The Center for Patient Safety has participated with other PSOs to
file briefs in these cases, supporting the protections available under
what the PSOs believe is the clear language of the Act and the Final
Rule. Important rulings will be published with a special alert to all
of the Center’s PSO participants.
THE CENTER FOR PATIENT SAFETY will continue to issue
immediate legal updates about important decisions. If PSO
participants or their attorneys have any questions, please contact
Kathy Wire at kwire@centerforpatientsafety.org.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016 2016
15

EMS FORWARD | IN THE COMMUNITY
NEW CPS REPORT SEEKS
TO RAISE EMS AWARENESS
BY LEE VARNER, MSEMS, EMT-P
Center for Patient Safety
Emergency Medical Services (EMS) is a special and unique profession with many dedicated men and
women. These professionals bring compassion, enthusiasm and dependability in often very challenging
environments. The Center for Patient Safety (CPS) is committed to provide support, resources and tools to
improve safety in the EMS setting. In light of that, CPS published the PS-10 Report to raise awareness of
patient safety concerns in EMS.
#EMSFORWARD
SAFETY TOPICS
• Airway Management
• Behavior Health
Encounters
• Crashes: Ambulance
and Helicopter
• Device Failures
• Medication Errors
• Mobile Integrated
Healthcare
• Pediatric Patients
• Safety Culture
• Second Victim Intervention
• Transition of Care
Ten Safety Topics for EMS
The ten selected safety topics are reflective of
those most often identified as risks to patient and
provider safety and are forecasted to be of greater
concern for EMS in 2016. This report is not an all-inclusive
list of the patient safety concerns in EMS, but
complements current patient safety and quality programs
and provides resources to take proactive steps
to eliminate harm.
It would be difficult for an organization to effectively
and efficiently address all ten topics in a
12-month period. Since many topics overlap, leaders
are encouraged to select one or two areas to implement
change and monitor improvement, which will
result in secondary benefits in other areas.
The topics in this report were selected following
a review by CPS experts and a review of leading EMS
industry publications and journals. CPS also analyzed
the PSO’s database of actual event information
from EMS providers nationwide. As one EMS leader
shared, “There is an illusion that EMS is so safe now -
[we] have forgotten how inherently dangerous it is”.
This PS-10 should be shared with frontline providers,
middle managers, and executive leaders. Click here
to download the PS-10: EMSForward report.
THE CENTER FOR PATIENT SAFETY is a private
not for profit organization that works across
the continuum of care to improve quality as
well as greater patient and provider safety. To
learn more contact Lee Varner at lvarner@
centerforpatientsafety.org.
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PSONEWS SUMMER SPRING 2016
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY

PATIENT SAFETY IN EMS | EMS SAFETY CONVERSATIONS
CPS UNVEILS NEW WEBSITE
The Center for Patient Safety (CPS) is
proud to announce the launch of its newly
revamped website. The site offers quick
and easy access to essential information,
resources and features while providing a
more comprehensive understanding of the
critical role that the Center plays in helping
promote safe and quality healthcare
through the reduction of medical errors.
The site, which went live on June 6,
also features comprehensive sections with
news, events and educational resources, as
well as a blog and corporate information.
As a PSO participant, we know your
access to resources is important. We’ve
worked to improve your access by providing
you with your own login information
to easily access the toolkit and participant-only
resources.
The new website boasts a clean design
aimed at improving functionality with
enhanced content and improved security
measures focused on helping CPS fulfill its
mission to promote a safe and just culture.
NEW CPS WEBSITE REQUIRES REGISTRATION
CPS’ new website will be updated on
a regular basis with news, resources, and
safety alerts and a newsletter aimed to
help healthcare organizations reduce medical
errors.
Visitors are encouraged to explore the
PARTICIPANTS ONLY:
DON'T MISS OUT ON ACCESS TO SPECIAL RESOURCES
1. Visit www.centerforpatientsafety.org
2. Select Members in the top right corner
3. Click on “Not A Member” to register a username
and password
4. Once approved, you’ll receive confirmation via
email
website and sign up for the Safety Snapshot
at www.centerforpatientsafety.org.
QUESTIONS about the new website?
Contact Jennifer Lux at jlux@
centerforpatientsafety.org.
PUT THE FOCUS ON SAFER
CARE IN EMS COMMUNITY
Early this year the CPS team started a pilot program to introduce the safety huddle concept to PSO
participants. One group that started the huddle pilot program was a select group of EMS medical directors.
What are huddles and how can they improve patient safety as well as the quality of care?
Huddles are timely, structured, secure and confidential conversations
that allow for discussions in a rapid-fire format that explore
real-time safety concerns. These virtual meetings provide an opportunity
to assess risk and share ways that mitigate future safety
concerns. Huddles are offered through the Center’s Patient Safety
Evaluation System, so conversations are protected by the federal
Patient Safety and Quality Improvement Act. The huddles have included
timely conversation on current issues with input to improve
event investigations and action planning.
AREAS OF RECENT DISCUSSION INCLUDE:
Airway Management: the importance of utilizing capnography
for airway monitoring as well as confirmation of airway placement.
Time Critical Diagnosis: early identification and transportation
to appropriate destinations for this patient population.
Transition of Care: Improving the hand-offs between providers
so that important information is not lost or omitted which might
contribute to an unsafe event reaching a patient.
Steps are underway by CPS staff to support process improvements
around these areas as well as collaborating with providers,
leaders and other stakeholders to improve and standardize the huddle
process. The CPS team looks forward to continuing the huddles
with EMS medical directors -- stay tuned for more opportunities in
the future. For more information, contact Lee Varner.
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016 2016
17

PSO PARTICIPANTS | DATA UPDATE
IMPORTANT UPDATE!
FOR PSO PARTICIPANTS...
ANNOUNCEMENTS
The Center for Patient Safety's PSO
continues to grow with new organizations
joining regularly. Participating organizations
have reported thousands of events
in 2016 so far. The reported information is
used for sharing and learning purposes.
Following review and analyses of the
reported events, CPS has issued more than
a half dozen watches and alerts as mechanisms
to raise awareness about the patient
safety trends reported to the PSO.
PATIENT SAFETY
ALERTS AND WATCHES
ISSUED
1. AHRQ Guidance
2. Contaminated Supplies
3. Home Health Medication
Management
4. Patient Destination
Decisions
5. EKG Strips
6. Intranasal Medication
Administration
7. Find more online
CPS is excited to announce several new
services and features for PSO participants:
1. We have made an investment in analytical
software, SAS, to expand on
current analyses and provide more
robust reporting to participants.
You'll see more on this soon!
2. VergeSolutions is preparing to
roll out enhanced options within
their data collection portal. One
new feature will allow for secure
communication about events from
participant to PSO and vice-a-versa.
Stay tuned!
3. We've launched a new website with
specific member access for you.
When logged in, you'll have direct
access to your toolkits, huddle
report-outs, and more, as well as a
new Q&A area to ask and answer
questions from other participants.
See the page 17 for details about
setting up your access!
2016 DATA UPDATE
Data submitted to the Center for Patient
Safety's PSO for 2016 reveals an increase in
the number of reported medication events.
Of the medication events reported:
• 60 events were associated with
opioids
• 36 were associated with benzodiazepines
• 3 events were associated with a
handoff to or from another unit
• The most commonly cited contributing
factor was the human factor
of inattention with communication
among staff and team members
being the second most commonly
cited contributing factor.
Please see our 2015 Annual PSO Report
for resources to improve communication
and tools for decreasing medication
events.
2016 EVENTS (JAN-JUN)
Type of Event
# of Events
Blood 20
Device 71
Falls 826
HAI 24
Medication 1156
Perinatal 101
Pressure Ulcer 23
Surgery 303
VTE 2
Other 2906
Harm Level
# of Events
Death 8
Severe 9
Moderate 43
Mild 384
No harm 3668
Unknown 1370
18
PSONEWS SUMMER SPRING 2016
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY

TAKE
Benefits of CPS Safety
Culture Survey Services:
PATIENT SAFETY INSIDER | SAFETY CULTURE SURVEY
• Deepest feedback reports in the industry!
ADVANTAGE!
Anyone can use CPS safety culture survey services,
but CPS PSO Participants receive a 20% discount!
REQUEST A PROPOSAL TODAY!
• Comprehensive reports at the organization and
department-level!
• SAVE TIME & MONEY! Save 30+ hours of
administrative time. You'll need about 2 hours for
the entire process and we'll take care of the rest!
• ACCESSIBLE - online, anonymous survey with
access via computer, smart-phone, tablet, etc
• DATA ANALYSIS - data is analyzed for you
• SUPPORT - we'll talk with you about your results
and guide you to your next steps
Culture surveys now available for:
• Hospitals
• Ambulatory Surgery Centers
• Long Term Care
• Home Health
• Medical Offices
• Pharmacies
• EMS - NEW!
We want you to be successful!
PRICING IS AFFORDABLE FOR ORGANIZATIONS OF ALL SIZES
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG PSONEWS SUMMER SPRING 2016 2016
19

2410A HYDE PARK RD.
JEFFERSON CITY, MO. 65109
PHONE: 1.888.935.8272
www.centerforpatientsafety.org
The Center for Patient Safety,
established in 2005, is an
independent, not-for-profit
organization dedicated to
promoting safe and quality
healthcare through the
reduction of medical errors.
FOR MORE INFORMATION, CONTACT ANY MEMBER OF THE PSO TEAM:
ALEX CHRISTGEN, BS, CPPS
Interim Executive Director
achristgen@centerforpatientsafety.org
EUNICE HALVERSON, MA
Patient Safety Specialist
ehalverson@centerforpatientsafety.org
KATHRYN WIRE, JD, MBA, CPHRM
Project Manager
kwire@centerforpatientsafety.org
LEE VARNER, MS-EMS, EMT-P
Project Manager - EMS Services
lvarner@centerforpatientsafety.org
TINA HILMAS, RN, BSN
Project Manager
thilmas@centerforpatientsafety.org
MICHAEL HANDLER, MD, MMM, FACPE
Medical Director
AMY VOGELSMEIER, PHD, RN, GCNS-BC
Researcher/Data Analyst
JENNIFER LUX
Office Coordinator
jlux@centerforpatientsafety.org
WELCOME NEW STAFF!
AIMEE TERRELL
Administrative Assistant
aterrell@centerforpatientsafety.org
Find us. Follow us. Like us.
Visit www.centerforpatientsafety.org
for additional information on the
Center’s PSO activities, resources,
toolkits, upcoming events,
safety culture resources, and more.
If you have questions about any
Center resources or articles within
this newsletter, please contact the
Center for Patient Safety at:
info@centerforpatientsafety.org
or call 888.935.8272
NOTE: Some articles contained within this newsletter may reference materials available to
Center for Patient Safety PSO participants only.
The information obtained in this publication is for informational purposes only and does not constitute
legal, financial, or other professional advice. The Center for Patient Safety does not take any
responsibility for the content of information contained at links of third-party websites.