Lessons Learned

The No Pass Zone for Patient Safety

The following scenario is derived from incidents reported to CHPSO:

A stable, ventilator-dependent patient (KP) was placed in a room across from the nurses’ station. The nurse caring for this patient then received a post-operative patient whose condition was deteriorating. A code was called for the post-op patient and several staff in the area responded to assist. During this emergency, KP’s ventilator tubing had become disconnected and the ventilator started alarming. However, no one responded to the alarm until a custodian passing by approached the nurses’ station and notified the unit clerk that he had noticed an alarm coming from KP’s room for several minutes and wanted to make sure someone was notified. At this point, the clinical staff realized that KP was quickly deteriorating and immediately responded. Unfortunately, they could not resuscitate KP.

Diffuse responsibility is a recognized safety concern in clinical alarm management. In order to manage the large amount of noise in busy and monitored environments, clinicians often “tune out” alarms that are not related to their own patient assignment. There is an underlying assumption that someone else is responding to an alarm associated with another clinician’s patient. Personnel in the area who are not clinicians are intimidated by alarms and assume that a clinician will respond. One approach to solving this issue is to implement the “No Pass Zone.”


A Place to Make Mistakes: Simulation Centers

This article focuses on this Children’s Hospital Los Angeles (CHLA) video, outlined below.

Eight-month old Maddie Sims was ejected from a car and transported by EMS to the hospital. She was cyanotic on arrival. A team of Children’s Hospital Los Angeles (CHLA) techs, nurses and physicians packed around Maddie’s bedside.


Zero Really Means Zero – Retained Surgical Items
A complimentary program offered to Patient Safety First Hospitals

Zero really means Zero and Patient Safety First (PSF) is looking to engage all PSF participating hospitals in 2014 to have ZERO Retained Surgical Items. Maybe things are great with your sponge management practices and you haven’t had any events, BUT there is continual abrasion between hospital staff and medical staff around x-ray policies in the OR, needle management strategies, or cases of retained guidewires, device fragments or a retained instrument or towel. 


LEAD Academy Trains Managers to Be Successful Leaders

LEAD Academy is an intensive six-session, 12-module training experience using innovative tools and experiential learning to empower recently hired, newly appointed or previously untrained health care leaders to better understand and use their strengths. Designed for health care supervisors and managers, LEAD is built on the underlying principle that effective leadership requires productive relationships to support excellence in patient care, sustainable business objectives and a safe patient environment.


Patient Safety News Changing to Bi-Monthly Schedule for More In-Depth Reporting

We are pleased to announce that we have received nearly 150,000 event reports to date, and the number of hospitals submitting events is increasing. Proper analysis of selected events requires reading the textual narrative involved, which is time-intensive.

Consequently, CHPSO Patient Safety News, formerly issued monthly, will now be issued every other month. This change is intended to allow us to provide articles based upon deeper analysis of the events we are receiving.



The California Hospital Patient Safety Organization is one of the largest Patient Safety Organizations in the nation, serving hospitals in the Western United States. CHPSO confidentially collects and analyzes patient safety data, develops and shares best practices, and helps individual hospitals accelerate safety improvement. More than 300 institutions have joined in this quest to eliminate preventable patient harm. CHPSO collaborates with hospital associations to ensure an integrated approach.