Lessons Learned: The Alarm Challenge

We mined the CHPSO database to determine the most commonly reported alarm related incidents. These reported issues align with those identified by The Joint Commission.


Transitioning to New ISO Connector Standards

A typical patient can be connected to several devices to receive medications, fluids and nutrients. Unfortunately, these tubes can be misconnected. One example of a dangerous misconnection is when a patient received enteral feeding formula intravenously because the tubing intended for the feeding tube was connected to the IV instead. Organizations have tried different strategies to reduce the risk of these misconnections.


Provider-provider Communication: How Does Your EHR Measure Up?

An EHR can help promote patient safety, but its success is implementation-dependent. Hospital leaders conduct an assessment of goals for technical readiness. Along with the vendor, the hospital outlines an implementation plan. The plan is implemented, a group of hospital staff members are trained, and they go through a mock “go-live” and pilot test. An actual “go-live” goes without a hitch, perhaps a few minor glitches, but essentially, the EHR is implemented.


Strategies for Enhancing Perioperative Safety: Promoting Joy and Meaning in the Workforce

Julianne Morath, President/CEO of the Hospital Quality Institute (HQI), and Rhonda Filipp, director of quality & patient safety for CHPSO, a division of HQI, collaborated with Michael Cull of Vanderbilt University Medical Center to develop a recent publication for the October 2014 edition of AORN Journal, Strategies for Enhancing Perioperative Safety: Promoting Joy and Meaning in the Workforce. This article focuses on the recognition of workforce safety as a precondition of patient safety.


Risks Associated with Medication Reconciliation and Transitions of Care

Medication reconciliation is intended to ensure the accuracy of the medication list at each patient encounter. However, the medication lists are entered into electronic health records by a variety of individuals (both licensed and unlicensed) across different health care settings and are not always accurate. A significant patient safety hazard may occur when these lists are used to create hospital medication orders that result in the continuation of inaccurate and/or incorrect medications.


How do we decide what to put in our patient safety evaluation system (PSES)?
—S.G., a hospital in southern California

A patient safety evaluation system is the system you use to collect, manage, and analyze information (patient safety work product) for reporting to your patient safety organization, CHPSO. There is no one-size-fits-all policy; each health care facility has needs that others may not experience. It is important to keep in mind that the PSES can be an evolutionary document and it is beneficial to revisit it regularly. While most hospitals submit all incident reports and RCAs to CHPSO, some may only report specific event categories.


Upcoming events

Including the Annual HQI Conference, CHPSO hosts events, web seminars and member calls throughout the year, all focusing on patient safety.