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In the past 18 months, the Center for Patient Safety PSO collected nearly 500 reports of unlabeled or mislabeled lab specimens from more than two dozen PSO participants. Research suggests more than 160,000 specimen-related adverse patient events occur annually, suggesting these remain largely underreported errors. Contributing factors include the sheer number of specimens collected and transported and the largely manual process of specimen collection.  While most reports to the CPS PSO did not reflect severe patient outcomes, we know these events can lead to confusion, errors, and delays ..read more

In an ever-evolving healthcare landscape, patient safety remains a top priority for healthcare organizations nationwide that strive for excellence in providing the best possible care. Healthcare watchdogs and accreditation groups have components that require organizations to address culture change, a recognized key driver of quality care; however, adherence to certain components can be difficult. The most common way to address culture change is to administer a safety culture survey, using the resulting data to measure current culture performance. Many organizations struggle to administer a cu ..read more

We are excited to announce a partnership between the Center for Patient Safety and Dr. Susan Scott to provide the Second Victim/Peer Support Train-the-Trainer program in an on-demand format. Together, we've expanded the resources and enhanced the original training while maintaining the most important aspects of the program.   Whether you are developing a new program from scratch, enhancing an existing program, or simply looking for a more effective way to train your peer supporters, this program is flexible and has the components you'll need. The program includes a unique set of tools ..read more

The US District Court for the Eastern District of Missouri recently issued an opinion that underscores the potential value of PSO protections. The court's conclusion is succinct and clear: state peer review privilege doesn't apply in federal court ..read more

Today, as was the case in 1974, many Americans have limited understanding of how EMS works, but are deeply appreciative when EMS services are required. Today, as strong as ever, EMS providers across America stand ready to provide our patients and communities with exception care when illness and injury occur. Intensifying burdens such as the Covid-19 pandemic have taken a substantial cost – and even a sense of enhanced sacred duty – to be there when we are needed. Despite the increased demands of personal safety challenges, staffing shortages, mental health and well-being concerns, today’s EMS ..read more

We have heard voices on all sides of the RaDonda Vaught case and studied the published facts and analyses as they became available. We could add material to the public discussion, but that seems like shouting into an already-crowded space. Instead, we refer interested readers to the following resources, noting that much incorrect information has circulated. We also remind everyone that a proper response in a Just Culture does NOT depend on outcome and that Just Culture work is challenging but essential in cases like this. We are puzzled by Vanderbilt’s silence and lack of support for their nu ..read more