Lessons Learned

Doctor Who?
Telephone order authentication challenges

Case: from a event reported to CHPSO

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.


HQI Invites Hospital Participation for CalHEN 2.0

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 Name Change

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 Hospital Quality 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 all members.


PSWP Privilege: Submitting a Subset of Reports
-G.B. A hospital in Texas

Our hospital would like to submit reports to CHPSO, but wish only to submit medication errors. Do all the safety reports have the Patient Safety Work Product (PSWP) privilege?  

Dear G.B.,


The Patient Safety Chronicle

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.


Hospital Hardware Hacking

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):


CHPSO Mid-Year Update Delivered to Member Hospital CEOs

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.


New PSO Reporting System with NextPlane Solutions

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 for submission.