Lessons Learned

Recothrom: Error-prone packaging

Case report: A patient with hemophilia was receiving both intravenous coagulation factors for his hemophilia and topical human recombinant thrombin (Recothrom) to treat surgical wound oozing. The nurse took both coagulation factor and Recothrom into the patient’s room. After being interrupted by other urgent care needs, the nurse picked up the Recothrom and administered it intravenously. The patient coded but was successfully resuscitated since the nurse quickly recognized and openly acknowledged his error, enabling the code team to provide appropriate timely treatment.

Lessons Learned

Rolling Stools

Stools are a common source of falls for patients, visitors and staff. These chairs are not meant for long-term seating and are primarily used by staff. However, when left unattended, patients or their visitors will seek the vacant seat to rest or relax if all others are occupied. According to the Agency for Healthcare Research and Quality (AHRQ), between 700,000 and 1,000,000 people in the nation fall in hospitals each year. Stool falls reported in the CHPSO database were all unassisted and often led to visits to the ED for fractures or lacerations.


Does our hospital have to submit event report data to the PSO by January 1, 2017?
From C.W., a hospital in San Diego County

Section 1311(h) of the Affordable Care Act requires Qualified Health Plans (QHPs) to contract with certain hospitals that use patient safety evaluation systems (PSES) and implement comprehensive hospital discharge programs, and requires QHPs to contract with health care providers who implement health care quality improvement mechanisms. In the final rule, hospitals must meet the following criteria:


One Million!

September 29, CHPSO, a division of the Hospital Quality Institute, passed the momentous milestone of 1,000,000 safety reports collected. Reports contributed by CHPSO members build a predictive intelligence source for members. These reports represent unsafe conditions, near misses and harm across all severity levels. Findings are disseminated through discussions directly with hospitals, and during members-only safe table meetings and de-identified summaries are shared with the public.


CHPSO Now Offering CEs for Safe Table Participation

CHPSO is an approved continuing education (CE) provider by the California Board of Registered Nursing and will provide CHPSO members an opportunity to earn CEs. There are three upcoming safe table meetings in October:


HQI to Release Advance Preview of 2015 Maternity Data

During the week of Oct. 10, the Hospital Quality Institute (HQI) will email CEOs an advance preview of hospital-specific 2015 maternity performance data that will be publicly accessible at the end of October on www.calqualitycare.org. The data set is compiled by the California Hospital Assessment and Reporting Taskforce. HQI encourages hospitals to review their data before the release, expected at month end.