Dr. Smith hospitalized Mr. Jones, a diabetic with a right below-knee amputation, for treatment and assessment of continuing pain in the left leg. Two days later, Dr. Smith phoned the ward clerk with new orders for Jones. The clerk shared the orders with Jones’ nurse, who was puzzled by the orders: triple the current dose of morphine, ask Dr. Thomas to do a left below-knee amputation, and administer an enema. The nurse called back Dr. Smith to clarify. Dr. Smith denied ever giving such an order.
The Centers for Medicare & Medicaid Services (CMS) is expected to
soon award contracts for Hospital Engagement Networks (HENs) as
part of its Partnership for Patients initiative. The
Hospital Quality Institute (HQI) invites all California hospitals
to join forces on HQI’s HEN 2.0.
CHPSO is excited to announce a name change, from the California
Hospital Patient Safety Organization (CHPSO) to just CHPSO. The
logo is also redesigned to call out its parent organization, the
Institute. When founded, CHPSO solely focused on serving
California hospitals, but as the organization expanded to the
western United States and to other care settings, meeting the
unmet needs of providers and patients across the continuum of
care, it was only appropriate to have an identity inclusive of
CHPSO is pleased to announce a second publication, The Patient Safety Chronicle. Unlike the CHPSO Patient Safety News, which features original articles and information relevant to patient safety professionals, the Chronicle assembles hundreds of headline stories from other sources, providing a great way to keep up with the latest in patient safety world-wide.
On July 31 the FDA issued a safety alert encouraging health care facilities to stop using Hospira Symbiq pumps due to cybersecurity concerns. This is not the first alert concerning hospital equipment cybersecurity and certainly will not be the last. If a hospital must temporarily continue using Symbiq pumps until replacements are in place, the following temporary measures should be taken (FDA, 2015):
At the end of July 2015, CHPSO, a core program of the Hospital Quality Institute
(HQI), mailed a mid-year update to all hospitals indicating
their level of activity with CHPSO. The mailing included a
dashboard highlighting the number and types of safety reports
submitted to CHPSO, the hospital’s harm score, a listing of
newsletter subscribers, a percentage of safety reporting vendors
used by CHPSO member hospitals, and whether your hospital has
attended introductory calls or orientation webinars.
CHPSO has a new partnership with NextPlane Solutions,
improving our database usability, significantly simplifying
information transmission to CHPSO, and saving members the cost
and effort of specialized solutions. This partnership will also
free up CHPSO resources to directly serve our members’ needs.
With the previous system, reporting to CHPSO often required a
specialized vendor module. Terminology mapping was used to put
each event into a separate file in the proper taxonomy and format