Lessons Learned

Delays in Sepsis Identification and Treatment
Lessons Learned from the CHPSO Database

Delays in identification and treatment can have catastrophic consequences for patients with sepsis. At the least, patients may experience longer than necessary hospital stays from delays in care. In extreme cases, septic patients may die or may suffer severe harm, such as amputations, from delays in care. Information gleaned from safety events submitted to the CHPSO database can help determine which factors are associated with delays in sepsis care. Organizations can work with their team to address the factors contributing to unnecessary delays in sepsis identification and treatment.

Lessons Learned

Lessons Learned from Trends in the “Other” Safety Event Category

CHPSO recently completed an analysis of safety events submitted to the database in the first quarter of 2018 from the “Other” category of safety event reports. The “Other” category is one of the largest categories of events in the CHPSO database. It is designed for safety reports that do not fit into any of the eight categories as outlined by the Agency for Healthcare Research and Quality:


CHPSO Turns 10!
CHPSO celebrated its ten-year anniversary November 5

Originally named the California Hospital Patient Safety Organization, CHPSO, now known by its acronym, operates under the Patient Safety and Quality Improvement Act of 2005. Over 80 Patient Safety Organizations (PSO) are listed by the Agency for Healthcare Research and Quality (AHRQ). CHPSO is one of the first, largest and most transparent, providing healthcare organizations with a federal protection, Patient Safety Work Product (PSWP). Members share their safety events with CHPSO.


Maternity Session Recap from the 2018 HQI Conference
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Thank you again for attending the HQI Conference Maternity Session on Sunday, October 28. It was a privilege for HQI to have the session led by an all-star panel of CMQCC’s Elliott Main and Terri Deeds, UCSF’s Melissa Rosenstein, Providence St. Joseph Health’s David LaGrew, and HQI’s own, Kim Werkmeister. This session was made possible by the generous support and commitment to maternity care from Blue Shield of California and the California Health Care Foundation.

If you missed the session, there are several materials and resources free for your staff and patients:


C. diff Stinks!! An Interdisciplinary Approach to Combatting Hospital Acquired Clostridium difficile

Hospital acquired Clostridium difficile (C. diff) infections are a persistent and costly problem for patients and healthcare providers.