Patient Safety Authority

09/03/2026

We are now open to applications for our fall Master Class Writing Workshop in Quality Improvement Studies!

👉🏽 Did your facility complete a project to improve patient care? If you publish your work, other facilities can learn from it and replicate your success.

👉🏽 Our free, online workshop teaches healthcare workers to write quality improvement studies and submit them for publication.

👉🏽 Learn more and apply by Friday, September 25, for our fall 2026 session:

Submit your application by September 25, 2026! Our free online Master Class Writing Workshop in Quality Improvement Studies teaches you how to turn your QI project into a manuscript.

09/03/2026

September is Su***de Prevention Awareness Month:

Although suicides and attempted suicides that happen on inpatient psychiatric units present unique challenges to patient safety, most studies in the last 25 years have focused on patient populations outside the United States, which feature different rules, practices, resources, and cultures that may influence their findings. Many of these studies also included incidents that occurred off the unit, such as when patients absconded or shortly after discharge. In contrast, the present study draws attention to suicide-related events in the United States, specifically events reported in Pennsylvania from 2016 to 2025 that only occurred on the inpatient psychiatric unit.

This overlooked focus provides fresh insights into the demographics, methods, objects, locations, and temporal patterns involved with on-unit suicide-related events. For example, of the 143 event reports studied, 130 (91%) were attempted suicides and 13 (9%) were suicides, and 57% involved female patients; however, 85% of the completed suicides were by male patients. Neck compression was used in 57% of cases, and suicides by this method frequently involved ligature points. Events typically occurred in private areas, such as bedrooms and bathrooms, and most occurred within the first five days of admission, from October to March, during the evening shift (3 p.m. to 11:59 p.m.). These trends reveal opportunities for further study and strategies to prevent suicide-related events on inpatient psychiatric units.

Read more in this new article at PATIENT SAFETY:

By Matthew A. Taylor, Shawn Kepner. Although suicides and attempted suicides that happen on inpatient psychiatric units present unique challenges to patient safety, most studies in the last 25 years have focused on patient populations outside...

09/02/2026

ICYMI: Bullying and disruptive behaviors in healthcare undermine teamwork, communication, and trust, ultimately placing patients at risk. This webinar examined how these behaviors affect patient safety and offered practical strategies to promote a safer, more respectful workplace environment.

Shirley Dominick, MSN, RN-BC, patient safety advisor at the Patient Safety Authority, led this engaging educational session. Participants learned to define bullying and recognize bullying behaviors, understand how these behaviors compromised patient safety, and identify strategies to address and reduce workplace bullying.

Watch "Bullying in Healthcare: A Disruptive Force Linked to Compromised Patient Safety":

Bullying and disruptive behaviors in healthcare undermined teamwork...

08/31/2026

Join us on Tuesday, Sept. 22, at 1 p.m. EDT, for "Redefining Patient Safety Analyses: Lessons Learned From One Organization."

Most existing causal processes are linear, overly focused on deviation and the individual, and can feel onerous to frontline staff. As a result, healthcare team members who are not directly engaged in patient safety may feel disconnected from the investigation and analysis of patient safety events.

Join Andrea Colfer, MSN, RN; Ethan Larsen, PhD; and Emily Stiglich, BSN, RN, from Children's Hospital of Philadelphia, as they

- Discuss the need for a systems approach to patient safety analyses
- Appreciate the role of, and collaboration with, human factors engineers in analyzing patient safety events
- Examine an alternative framework and analysis tools beyond root cause analysis
- Describe one organization’s process for developing and utilizing new cause analysis tools

Register now for this free webinar at db2996cf-ccef-433e-a751-6f7a710c3d69@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/db2996cf-ccef-433e-a751-6f7a710c3d69@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

The Patient Safety Authority designated this webinar for a maximum of 1.0 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved for 1.0 nursing contact hour.

This activity was planned by and for the healthcare team, and learners will receive 1.0 Interprofessional Continuing Education (IPCE) credit for learning and change.

08/27/2026

Inconsistencies in event investigations result in less effective action plans to address identified patient safety concerns.

Join us on Wednesday, Sept. 16, at 12 p.m. EDT for "Rapid Investigation Teams: A Novel Approach to Responding to Patient Safety Events." In this free webinar, Cara Peck, MS, RN, senior manager, risk prevention and patient safety, Main Line Health, will describe the implementation of a centralized rapid investigation team within a multihospital health system, discuss strategies to improve consistency in root cause analysis facilitation, and identify approaches to strengthen organizational learning.

This activity is approved for 1.0 nursing contact hour.

Register now for this free webinar: 9939467e-15ea-4e2e-b7c6-5eeb6005521a@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/9939467e-15ea-4e2e-b7c6-5eeb6005521a@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

08/26/2026

Falls continue to be a significant patient safety concern in healthcare facilities across Pennsylvania. Outreach and interviews with patient safety staff have revealed that approaches to fall reduction vary widely, and many programs are not fully aligned with recognized best practices.

In this recorded webinar, Patient Safety Authority (PSA) patient safety advisors Richard Kundravi, BS, and Molly Quesenberry, BSN, RN, discuss opportunities to strengthen fall reduction programs using evidence‑based strategies and practical tools. They highlight how PSA’s Keys to Reducing Falls tool can help facilities assess current practices, identify gaps, and implement effective interventions to reduce falls and fall-related injuries.

Watch and share:

Falls continued to be a significant patient safety concern in healt...

08/25/2026

The Hospital + Healthsystem Association of Pennsylvania's 2026 Patient Safety, Quality, and Equity Symposium (Sept. 2 and 3, Hershey Lodge) offers a dynamic platform for healthcare leaders, clinicians, and quality improvement professionals to come together in pursuit of safer, more equitable, and higher-quality care across the commonwealth.

The symposium will feature discussions on timely challenges, innovative strategies to improve outcomes, and lessons learned from across the care continuum. Focus areas include health disparities, patient and workplace safety, and equity in care delivery. The event also celebrates the diverse and impactful work happening in Pennsylvania hospitals—highlighting the shared commitment to improving care for all patients and communities.

Don't miss PSA's presentation on Wednesday, September 2, at 11:25 a.m., Strengthening Patient Safety Through Standardized Reporting and Obstetrical Risk Reduction: Michelle Bell, BSN, RN, director of Outreach & Education, will provide an update on two key patient safety initiatives.

Learn about the newly released Reporting Standardization Guidance, developed jointly with the Pennsylvania Department of Health, which clarifies expectations for reporting serious events, incidents, and infrastructure failures under the MCARE Act, as well as upcoming Pennsylvania Patient Safety Reporting System (PA-PSRS) changes taking effect January 1, 2027. The session will also highlight PSA's advisory on shoulder dystocia, including strategies to strengthen obstetrical safety through consistent risk assessment, team preparedness, and patient counseling.

Register now at

HAP’s Patient Safety, Quality, and Equity Symposium provides the setting for health care leaders to discuss the opportunities and challenges for the future; network and learn from each other; and celebrate the diversity and scope of Pennsylvania hospitals’ accomplishments.

08/24/2026

Join us this Thursday, Aug. 27, at 11 a.m. EDT for a free webinar, "The Power of Patient Safety Data."

Healthcare professionals frequently collect patient safety data, but many lack the knowledge and structured processes needed to interpret these data and translate findings into meaningful improvement actions. This gap results in underutilized opportunities to identify risks, apply evidence-based interventions, engage interdisciplinary teams, and measure impact. Addressing this gap will help the healthcare team more effectively use data to guide patient safety and quality improvement efforts.

Join Uniontown Hospital's Andrea Atkinson, Christy Kitta, and Ziad Dimachkie, as they

- Describe how patient safety data can be transformed into actionable insights to improve patient safety outcomes
- Identify key sources of patient safety data and describe how each contributes to understanding safety gaps
- Recognize strategies for engaging interdisciplinary teams and leadership in data-informed patient safety improvement efforts

Register now at 23860e83-8b01-49d3-b821-f41e6435585a@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/23860e83-8b01-49d3-b821-f41e6435585a@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

The Patient Safety Authority designated this webinar for a maximum of 1.0 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is approved for 1.0 nursing contact hour.

This activity was planned by and for the healthcare team, and learners will receive 1.0 Interprofessional Continuing Education (IPCE) credit for learning and change.

08/18/2026

Many people with Type 1 or Type 2 diabetes use continuous glucose monitors (CGMs). These small wearable devices help track blood sugar levels throughout the day. Even though people commonly use continuous glucose monitors at home, hospitals have been slower to allow their use. This is due to uncertainty concerning their safety and accuracy in a clinical setting, versus the standard procedure of finger-stick blood testing several times a day. However, recent research, and the Food and Drug Administration’s temporary approval of in-hospital CGM use during the height of the COVID-19 pandemic, suggest that when used correctly, CGMs can be a reliable alternative to finger-stick tests, as well as offer additional benefits in monitoring and maintaining glucose levels of inpatients.

A recent review by Patient Safety Authority research scientists discovered that inpatient CGM use can be associated with both an increased and decreased risk of harm. Researchers found that when CGMs increased risk of harm, issues such as off-policy blood glucose monitoring, missing documentation, and unauthorized insulin administration occurred. However, the data representing a decreased risk of harm associated with CGM use highlights the potential for CGMs to be useful tools during a hospital stay. As CGM usage increases due to patient preferences and shifting hospital policies, facilities should consider the strategies outlined in this article and establish clear, consistent procedures and collaborative communication between patients and providers to foster safe, effective CGM use.

Read more:

By Christine E. Sanchez, Myungsun Ro & 1 more. Data from this study showed that inpatient CGM use was associated with both increased and reduced risk of patient harm. Clear policies and consistent patient-provider communication may help to minimize...

08/05/2026

Just published: Accurate identification and use of s*x assigned at birth (SAAB) and gender identity information are imperative for trans and gender-diverse (TGD) patient safety. Previous studies and literature reveal that miscommunication and/or misidentification of either SAAB or gender identity do occur, and this creates risk of patient harm and erroneous care. We reviewed a sample of event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in which the patients involved were TGD and the event was described as involving inaccurate identification of or inattention to SAAB and/or gender identity information.

This article includes vignettes from a sample of the event reports and explores the clinical implications of inaccurate identification of or inattention to SAAB or gender identity information, as well as strategies for improvement.

Read more in PATIENT SAFETY:

By Matthew A. Taylor. Accurate identification and use of s*x assigned at birth (SAAB) and gender identity information are imperative for trans and gender-diverse (TGD) patient safety.