Lessons Learned

Lessons learned from the CHPSO database

Restraints are sometimes necessary for the protection of the patient or others. As Centers for Medicare and Medicaid Services (CMS) states, “The use of restraint or seclusion must be selected only when less restrictive measures have been judged to be ineffective to protect the patient or others from harm.

Lessons Learned

Childbirth after Prior Cesarean

A 31 year-old Gravida 6 Para 5 (6 pregnancies, 5 births) at 40 weeks gestation arrived at her local hospital with ruptured membranes and uterine contractions every 3-5 minutes. On exam by the nurse, the mother was 5 cms dilated, 75 percent effaced, cephalic presentation at -2 station. The amniotic fluid was clear and the fetal heart tone tracing was Category I (normal). She denied any significant health history or major surgeries, including prior cesarean births.


What can we learn from spontaneous reporting systems?

In a recent Acute Care ISMP Medication Safety Alert, the Institute for Safe Medication Practices (ISMP) reviewed the FDA Adverse Event Reporting System (FAERS) for reports submitted during 2017. The following table summarizes their findings for rhabdomyolysis, a potentially life-threatening side-effect of certain drugs.


2018 HQI Conference Discount Deadline, Sept. 28
Fifth Annual HQI Conference held in Huntington Beach, CA

The 2018 Hospital Quality Institute Conference, to take place Oct. 28-30, will help hospital staff, health care providers, students and residents achieve increasing levels of performance through a culture of respect and professionalism. Attendees will learn strategies and take home tools for achieving reliable care and delivering value to each patient, each time and in each community.


Smart Care California to Recognize Hospitals with Low C-Section Rates
California birthing hospitals may preview maternity rates next week

Under the Healthy People 2020 initiative, hospitals are encouraged to reduce rates of elective cesarean deliveries for low-risk, first-time births to less than 23.9 percent. Since 2016, Smart Care California has included hospitals that have achieved that milestone on its hospital honor roll. The honor roll — a collaborative effort among stakeholders that represent policy, purchases, providers and quality improvement organizations — will be announced the week of Oct. 22.


Rory Jaffe to Retire

Dr. Rory Jaffe, Executive Director and Founder of CHPSO Patient Safety Organization will retire at the end of the year. Rory and the “small but mighty” CHPSO team have built our PSO to become the longest tenured and largest in the United States with over 400 members from Hawaii to Rhode Island. With over 1.8 million safety reports in the CHPSO database, alerts and lessons learned on how to improve health care reliability and safety have been shared publicly to the CHPSO community.


Job Board

Quality and patient safety positions at your organization may be listed on the CHPSO Job Board free of charge.


Rapid Precision Medicine Grand Rounds

Join the growing learning network in Rapid Precision Medicine

Sept. 26, 2018

“Introduction To Guinness World Record Rapid Whole Genome Sequencing: A 17-month old boy presenting with fever, fussiness, vomiting, diarrhea and skin rash.”

Presented by Stephen Kingsmore, MD, DSc
President and CEO, Rady Children’s Institute for Genomic Medicine