CHPSO 2015 Annual Report

The CHPSO 2015 Annual Report, which covers the period January 1 – December 31, 2015, focuses on CHPSO’s year in review with highlights for 2016. The Report is available online on the CHPSO website.

Lessons Learned

Infants Fall Too

Case: A nursing mother fell asleep in the hospital bed and her newborn slipped out of her arms, falling to the floor. The mother had been on painkillers that made her drowsy. The infant was taken for a CT that showed a skull fracture. There were no family members in the patient’s room when the incident occurred.

In a preliminary search of CHPSO falls and perinatal events, approximately 35 in-hospital infant falls from 2014-2015 were due to the following:


Annual CHPSO Member Reports Mailed

Each year, CHPSO provides member hospitals with feedback on the data the health care facility submitted to CHPSO. The feedback includes information on the quality and tone of reports, in addition to recommendations based on the reports that were shared. Additionally, the reports include a dashboard entailing the number of reports submitted by category for the hospital and the number of reports submitted by category for the year by all CHPSO members.


Who May Use PSWP in Our Organization?
— E.D., from a hospital in Northern California

Those who are a part of the work force at the CHPSO member organization can use PSWP. These are hospital staff including technicians, nurses, and physicians, a well as those who are contractors, including legal counsel. The PSWP can be used for any purpose and it does not have to be de-identified. PSWP can be used across different committees and meetings; however, it cannot be used in a peer review disciplinary hearing. 


Upcoming Member only CHPSO Safe Table Forum
The topic of discussion is Alarm Management.

CHPSO and HCNCC invite you to attend Safe Table Forum in Sacramento, CA on April 19, 2016 from 10:00 a.m. – 1:00 p.m. The topic of discussion is Alarm Management.