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Quality and Patient Safety Newsletters

Here is an archive of QPSD newsletters

The Quality and Patient Safety Division Newsletter, FIRST Do No Harm, is a vehicle for sharing quality and patient safety initiatives of Massachusetts healthcare facilities and the work of the Quality and Patient Safety Division and Committee. Publication of this Newsletter does not constitute an endorsement by the Board of any studies or practices described in the Newsletters and none should be inferred.

QPS Newsletters


  • May 2015 
    • Baystate Medical Center – Redesigned Rapid Response Team
    • BIDMC HouseStaff Quality Improvement Council
    • Cambridge Health Alliance – Lessons Learned from Power Outage


  •   November 2014 
    • Boston Medical Center Risk Stratified VTE Prophylaxis Protocol
    • Hebrew Senior Life TIPS Conferences
    • Anna Jaques Hospital “Patient Story” CME Program
    • SQR Corner—MRI Safety
  • NOTICE – Article on Delirium Protocol at Steward Hospitals 
  • June 2014 
    • Steward RBC Transfusion Practices
    • Improving PCA Safety at BWH
    • SQR Corner: Intra-op Arrhythmia
    • Notice - Uterine Power Morcellation
  • April 2014 
    In this ASC Issue:
    • DVT Risk Assessment
    • Advanced Directives
    • Anticoagulation in Endoscopy
    • Diabetes Management
  • January 2014 
    • NSMC – family rounds in ICUs
    • DFCI - PFAC member experiences
    • Baystate Health's Quality Report


  • August 2013 
    • Spaulding Rehab: FMEA for move to new hospital
    • New Bedford Rehab: volumetric capnography for vent weaning
    • Boston Medical: medications “in hand” for discharged asthma patients
    • New England Baptist : pre-surgical risk assessment & planning
  • June 2013 
    In this first ASC Issue:
    • ISO Implementation
    • Safe Discharges
    • Pre-admission Documentation
    • Obtaining Post-Discharge Information
    • Preventing Skin Tears
    • QPSD Notes
  • April 2013 
    • Jim Conway Leadership/Preoccupation with Failure”

    • North Shore Medical Center- Accurate Weights in CHF Patients
    • UMass Medical Center–RCA Process
    • “Lessons Learned” and SQR Examples
  • March 2013 
    This issue includes The Four Habits Series:
    • Beth Israel Deaconess Medical Center and Winchester Hospital - Eliminating Preventable Harm


  • December 2012 
    This issue includes Handoff Communication Tools.
    • Boston Children’s Hospital I-PASS
    • Southcoast-EMS Transport Handoffs
    • Hallmark-Nursing Bedside Handoffs
    • BWH Faulkner-Standardizing Handoffs
    • QPS Notes & Updates
  • September 2012 
    This issue includes New England Baptist Hospital and Beth Israel Deaconess Medical Center descriptions of their processes to Prevent Wrong Level Spine Surgery. 
  • August 2012 
    This issue includes:
    • St. Vincent Hospital's ICU Early Ambulation Program
    • Emerson Hospital Reduces HAIs
    • Creating a Culture of Respect - Interview with Lucian Leape, MD
    • ASC Update
    • QPSD Notes & Updates
  • July 2012 
    This issue includes The Four Habits Series:
    • Baystate Franklin & Northern Region “Service Excellence”
    • Boston Medical Center “Exceptional Care without Exception”
  • April 2012 
    This issue includes:
    • Boston Medical Center's Emergency Airway Response Team
    • Sturdy Hospital End of Life Planning
    • ASC Update
    • QPSD Update
    • SQR Corner-Spiral Endoscopy
  • March 2012 
    This issue includes Massachusetts General Hospital Case Study: Physiological Alarm Monitoring.