The Commission, in partnership with Demi Haffenreffer, Patti Garibaldi and Morgen Brodie, conducted eight statewide Root Cause Analysis (RCA ) trainings for state agency staff and long term care providers in the spring of 2010. RCA tools, PowerPoint presentation and a condensed version of the guide can be found here.

Become part of a seamless transition; join 15 statewide Oregon health care providers in addressing concerns around patient transitions between care settings. Our goal is to form real solutions that improve patient care quality and safety, and reduce health care costs. Apply by Sept. 13.

Washington Patient Safety Coalition will present "Safe Care of the Very Large Patient" Oct. 21, Spokane, WA. Challenge assumptions on how best to care for this population while keeping staff safe. Register below; see also links to material from the April 6 Oregon conference on this topic.

The Oregon IHI Network, including the Patient Safety Commission, worked with Oregon leadership of Advancing Excellence in Americas Nursing Homes to develop cross-setting interventions for transitional care, with an initial focus on pressure ulcers. We support use of this toolkit to improve pressure ulcer prevention and care in Oregon.

New England Journal of Medicine reports that use of a simple checklist significantly reduces surgical complications and death.

Over half of all Oregon ASCs have joined the Commission's adverse event reporting program. Amy Carl is the Patient Safety Commission's Field Coordinator for ambulatory surgery centers. You can reach Amy at 503.227.2632 or E-mail her at amy.carl@oregonpatientsafety.org.

56 of Oregon's 58 hospitals participate in the adverse event reporting program. Leslie Ray is the Commission's Field Coordinator for hospitals. You can reach Leslie at 503.224.9227 or E-mail her at leslie.ray@oregonpatientsafety.org.

Over 75% of Oregon's nursing homes have agreed to participate in the adverse event reporting program. Amy Carl is the Commission's Field Coordinator for nursing homes. You can reach Amy at 503.227.2632 or E-mail her at amy.carl@oregonpatientsafety.org.

A growing number of retail pharmacies have joined Oregon's innovative adverse event reporting program. Leslie Ray is the Commission's Field Coordinator for retail pharmacies. You can reach Leslie at 503.224.9227 or E-mail her at leslie.ray@oregonpatientsafety.org.