The Movement is not just about information, it is about action! By addressing new challenges and forming Actionable Patient Safety Solutions (APSS) the PSMF believes we can reduce the number of preventable deaths in hospitals to ZERO.

Below you will find links to 18 challenges and 30+ solutions to overcome some of the leading patient safety challenges facing hospitals today. Please take the time to download and share these APSS with your colleagues. If you haven’t made a commitment to implement these solutions, please make a commitment today.

  • Challenge 1: Culture of Safety

    A Culture of Safety within a healthcare organization refers to a safe and reliable environment where the foundation of transparency, safety, trust, and accountability is established and maintained between the workers of the facility and the patients it serves. Read More

  • Challenge 2: Healthcare-associated Infections (HAIs)

    Healthcare-associated infections (HAIs) are infections patients acquire while being treated in a healthcare facility. HAIs are serious and, often times, preventable if an actionable prevention plan is in place and best practices to safely manage these infections are implemented across the organization. PSMF currently focuses on the following topics related to HAIs: Hand Hygiene, Catheter-associated Urinary Tract Infections (CAUTI), Surgical Site Infections (SSI), Ventilator-associated Pneumonia (VAP), Clostridium Difficile Infection (CDI), and Central Line-associated Blood Stream Infections (CLABSI). Read More

  • Challenge 3: Medication Safety

    A medication error is a preventable event in any healthcare setting that may lead to inappropriate medication use while in the control of the healthcare professional or patient, ultimately leading to patient harm and/or death. Medication errors can be classified into five categories: 1) wrong drug, 2) wrong dose, 3) wrong route, 4) wrong frequency and/or 5) wrong patient. Read More

  • Challenge 4: Monitoring for Opioid-induced Respiratory Depression

    When a patient dies because of a complication that was not recognized in a timely manner, or treated appropriately, that death is preventable and is called "Failure to Rescue." While opioid use is safe for most patients, opioid analgesics are associated with adverse effects and cause respiratory depression in a significant number of post-surgical patients, who often receive them for pain management. Read More

  • Challenge 5: Patient Blood Management

    Anemia is a condition marked by a deficiency of red blood cells (RBC) or of hemoglobin (Hb), which is the protein present in red blood cells that allows for the transport of oxygen through the body. Due to the lack of oxygen, a patient can experience fatigue, pale skin, dizziness, nausea, and many other symptoms. RBC transfusions are administered to patients during active bleeding, chronic blood loss or poor production in order to increase the body’s oxygen carrying capacity. Despite the perceived benefit, many RBC transfusions have been deemed unnecessary resulting in risk or harm and defined as “overuse”. Read More

  • Challenge 6: Hand-off Communications

    Hand-off communications, or hand-off processes, involve the transition of care as well as the transfer of patient-specific information by one healthcare professional to another with the purpose of providing a patient with safe, continuous care. A successful hand-off can only be achieved by effective communication. Read More

  • Challenge 7: Neonatal Safety

    Neonatal safety addresses patient safety in the context of a vulnerable group of patients, newborns or neonates. Improving neonatal care and safety reduces harm, prevents adverse events from taking place, and optimizes the care of newborns in the healthcare setting. PSMF is currently focused on two critical and common neonatal safety challenges: Suboptimal Neonatal Oxygen Targeting and Failure to Detect Critical Congenital Heart Disease (CCHD). Read More

  • Challenge 8: Airway Safety

    Airway safety refers to the management and monitoring of the respiratory tract (i.e. mouth, nose, lungs) to ensure air is properly transported to the lungs avoiding any complications that may arise, such as the need for intubation (placing a tube down the trachea) or an unplanned extubation (the tube being dislodged from the trachea before it is ready to be removed). Read More

  • Challenge 9: Early Detection and Treatment Of Sepsis

    Sepsis occurs when the body reacts to an infection and releases chemicals that cause inflammation as well as organ failure. Early detection of sepsis, with the timely administration of appropriate fluids and antibiotics, appear to be the single most important factors in reducing morbidity and mortality from sepsis. It has become increasingly apparent that there is a long delay in both the recognition of sepsis and the initiation of appropriate therapy in many patients. This translates into an increased incidence of progressive organ failure and a higher mortality. Healthcare providers, therefore, need to have a high index of suspicion for the presence of sepsis and must begin appropriate interventions quickly. Read More

  • Challenge 10: Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest

    Optimal Resuscitation often occurs in emergency medicine, trauma surgery, and intensive care medicine when a healthcare professional is able to intervene in a way that corrects breathing or a declining heartbeat; in doing so, the patient is revived or taken away from the pathway to death. Read More

  • Challenge 11: Optimizing Obstetric Safety

    Obstetric safety, or the safety of women who are giving birth, focuses on improving the quality of care delivered to soon-to-be mothers. The goal is to improve the early recognition, readiness, and responsiveness of healthcare professionals treating these women. The PSMF is focused on the following obstetric-related challenges: pre-eclampsia, postpartum hemorrhage (PPH), and unnecessary c-sections. Read More

  • Challenge 12: Embolic Events

    An embolic event or "embolism" describes a process by which any substance that does not readily dissolve in blood enters the circulation.  Embolic substances can be solid, liquid, or gas.  Examples include blood clots, fat, air, bone marrow, amniotic fluid, and cement used in joint prostheses.  Once they enter the circulation, usually on the venous side, embolisms (or "emboli") have two possible pathways.  Most often, they follow the venous blood flow through the right side of the heart, and then travel through the pulmonary arteries to the lungs.  Here they can do serious or even fatal harm by blocking the blood flow to portions of the lungs.  Many people (30% in one study) have undiagnosed pathways from the pulmonary (right-heart) to the arterial (left-heart) circulation, and in these patients a venous embolism can bypass the lungs to become an arterial embolism.  These "paradoxical emboli" can block the circulation to vital organs, particularly the brain or heart.  Small emboli that would do only minor damage in the lungs can cause fatal harm to the brain or heart by this mechanism. The most common source of embolism is blood clot (thrombus) from the periphery, usually from the leg veins.  These venous clots can break loose from the walls of the vein in which they were formed (e.g., the saphenous vein) and thus enter the circulation.  This mechanism of "Deep Venous Thrombosis" or "DVT" is the subject of APSS 12A.  Another common embolic mechanism is the admission or air into the venous circulation, which can occur in trauma, during surgery, or by inadvertent injection of air into any type of venous access catheter.  "Air Embolism" is the topic of APSS 12B.  In both of these subAPSS, we discuss the prevention, early detection or diagnosis, and emergency treatment of the embolic event.  Other subAPSS for future development may include fat, marrow, and amniotic fluid embolism. Read More

  • Challenge 13: Mental Health

    Patient safety events in psychiatry units are a serious concern; over 1,500 suicides take place on in-patient psychiatry units in the United States alone each year, over 70% by hanging. The overarching lack of access to acute psychiatric beds refers to an inadequacy of psychiatric beds in hospitals and makes for a deficiency in a patients overall mental health treatment. This lack not only leads to a higher rate of suicide and a lower quality of life for patients in desperate need of mental health treatment but can also create greater expenses for the public health system if patients are not properly treated. Read More

  • Challenge 14: Falls and Fall Prevention

    Every second an older adult falls in America. The Centers for Disease Control and Prevention (CDC) estimates that approximately 2.8 million older adults are treated in emergency departments for fall injuries every year, including 800,000 hospitalizations and more than 27,000 deaths. The Agency for Healthcare Research and Quality (AHRQ) reports that between 700,000 and a million people fall in the hospital each year. Significant research has been conducted over the last several decades to minimize harm and mortality due to falls but the topic still remains one of the great challenges facing hospitals today. Read More

  • Challenge 15: Nasogastric Tube (NGT) Placement and Verification

    A nasogastric or NG tube is a plastic tubing device that allows delivery of nutrition directly into the stomach (feeding), or removal of stomach contents (drainage). It is passed via the nose into the oropharynx and upper gastrointestinal tract. Many times these tubes can be malpositioned, leading to significant harm and even death. The National Health Service Improvement (NHSI) in the United Kingdom has placed this type of incident on their “never events” list; never events are “errors in medical care that are identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.” (National Quality Forum) Read More

  • Challenge 16: Person and Family Engagement

    Person and Family Engagement (PFE) is an underused “natural resource” for improving the safety of care. Users of healthcare and their family members play substantial roles in managing care and often see and learn things that care providers and researchers miss. If their observations, insights and lessons learned are overlooked in safety improvement, the organization loses important opportunities to prevent harm. In 2013 then Health Affairs Editor Susan Dentzer recognized the value of PFE in characterizing it as the "blockbuster drug” of the 21st Century, observing: Read More

  • Challenge 17: Patient Safety Curriculum

    The Patient Safety Movement Foundation will place significant energy into Patient Safety Curriculum & Education development for healthcare professionals from 2018-2020. We have assembled a Workgroup to create a core curriculum that can be applied across all health professions. Dr. Steven Scheinman and Dr. Margrit (Peggy) Shoemaker, from Geisinger Commonwealth, Co-Chair the Patient Safety Movement Foundation’s Patient Safety Curriculum Workgroup. This dedicated group is in the midst of developing core curricula which will include the following elements: Ownership of patient safety and quality embedded within the professional identity formation for all health caregivers; Core curriculum common to all health professions. The fundamental elements of the core curriculum will include: Leadership training Interprofessional team-based models Definition of competencies to be achieved, outcomes to be assessed and milestones (which will be specialty-specific) to be identified for each stage of one’s professional career (UME, GME and unsupervised practice, across all professions) Focusing beyond care of the individual patient to address systems of care Read More

  • Challenge 18: Post-operative Delirium in Older Adults

    Delirium is a condition of acute cerebral dysfunction and maybe seen in the early postoperative period or in the ICU patient. It occurs frequently in elderly patients and the diagnosis is missed as hypoactivity occurs in the majority of patients, but in some patients, it is hyperactivity and needs immediate intervention. It is predictive of cognitive decline, longer time in the hospital, and increased mortality. Recent studies have demonstrated a signature of dementia on EEG that may open doors to early diagnosis, etiology, treatment and prevention. The PSMF has taken this on as its latest challenge to save lives. Read More