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Continuing efforts to encourage each healthcare worker in Pennsylvania’s healthcare facilities to make a personal commitment to patient safety, the Pennsylvania Patient Safety Authority has featured 10 individuals and groups on posters who have committed themselves to patient safety within their healthcare facilities. The posters were developed for display during National Patient Safety Awareness Week March 3-9, 2014.
In the last few months, the Authority held its first “I am Patient Safety” poster contest to highlight individuals and groups who have made a personal commitment to patient safety. The contest coincides with a campaign the Authority began last year for National Patient Safety Awareness week in which the Authority developed posters with a checklist of what healthcare personnel can do individually to promote a culture of safety and/or improve patient safety in their facility.
“Patient Safety Awareness Week is a great time for the Authority to recognize those individuals and groups within Pennsylvania’s healthcare facilities who have taken the steps necessary to improve patient safety within their facility,” says Mike Doering, executive director of the Pennsylvania Patient Safety Authority. “The healthcare workers featured on the posters range from doctors to administrative and housekeeping personnel. “As one of the judges of the panel, I was impressed with the number of patient safety improvements individuals and groups are making throughout Pennsylvania and I appreciate the time taken by healthcare personnel who submitted entries for the contest to tell us about them."
The judging panel for the poster contest was comprised of Patient Safety Authority board members and management staff. Submissions were judged according to the following criteria: had a discernable impact on patient safety to one or many patients, demonstrated a personal commitment to patient safety, and demonstrated that a strong patient safety culture is present in the facility. Bonus points were awarded for those who demonstrated initiative taken by an individual. Winners received their photo and patient safety efforts highlighted on posters which can be displayed within their facilities. They also received a certificate and “I am Patient Safety” recognition pin from the Authority.
“Every day, healthcare facility personnel work to improve patient safety and help keep patients safe from harm when using the healthcare system. These posters help us to congratulate some of them on a job well done,” Doering adds.
The individuals and groups recognized for the “I am Patient Safety” poster contest and their achievements are as follows (in alphabetical order):
Sharon Best, Housekeeper 1, Environmental Services (former employee)
Children’s Hospital of Pittsburgh of UPMC
Sharon “knew something was not right” with a patient while she was cleaning his room. Sharon’s awareness and immediate action to get help for the patient, who was having a seizure, showed her commitment to patient safety.
Terri Bugnizet, RN, BSN, CEN, CPEN, Emergency Department
Chester County Hospital-Penn Medicine
While Terri was reviewing a medication order for a diabetic patient in the emergency room, she noticed that a physician had incorrectly ordered a one-time dose and type of insulin that could have resulted in a serious medication event and injury to the patient. Thanks to Terri’s attention to detail, the patient received the correct type and dose of insulin.
Kelly Crist, Transcriptionist Unit Clerk, Imaging Services
WellSpan Gettysburg Hospital
[Submitted with Kimberly Wolfe] Kelly pointed out to the appropriate staff the correct test results for her patient. Kelly ensured timely and accurate communication of critical test results, which allowed for immediate and necessary treatment of her patient.
Kathleen Fowler, MSN, RN, CMSRN, Quality Improvement Project Manager
UPMC St. Margaret of Pittsburgh
Kathleen’s commitment to patient safety led to implementation of several process improvements to decrease falls with injury. Kathleen facilitated the implementation of the Safe Patient Handling Campaign, which led to a reduction in the number of injuries experienced by staff when handling or moving patients during care activities. Kathleen also modified the just culture initiative for UPMC St. Margaret to encourage staff to learn from events occurring in the facility.
Tim McFeely, RN, BSN, NE-BC, Nurse Manager of the Coronary Care Unit
WellSpan York Hospital
As nurse manager of the Coronary Care Unit and chair of the resuscitation review team at WellSpan York Hospital, Tim ensures his team looks at every resuscitation event in the hospital. He works with his team to dig deep and find every reason why American Heart Association guideline targets are not met. Tim regularly shares best practices with his nursing staff, along with outcomes. Through Tim’s leadership, post-cardiac-arrest survival-to-discharge improved from 17.2% in 2011 to 31.6% in 2012.
Ann Norwich, CRNP WellSpan Gettysburg Hospitalist Service
WellSpan Gettysburg Hospital
Ann assumed care of a patient admitted with an altered mental status whose cognitive condition did not improve after treatment for an underlying infection. After hours of research, Ann discovered a significant medication error that occurred on admission and contributed to the patient’s altered mental state. The medication error was corrected and reported immediately. During investigation of this event, a previously unknown problem with the electronic medication reconciliation and ordering process was revealed. Without Ann’s persistence in trying to understand this patient’s situation, this latent error might have gone undiscovered.
Regional Gastroenterology Associates of Lancaster (RGAL)
Patient Safety Committee Team Leaders
Jennifer Bean, BSN, RN, Clinical Coordinator and Infection Control; Trudy Chernich, Patient Safety Committee Community Representative; Judy Fry, Health Information Team Leader; Valerie Geyer, MSN, RN, NE-BC, Director of Clinical Services; Denise Jackson, Billing Associate; Linda Leayman, Manager, Patient Relations; Elsie Lunger, LPN, Open Access; Cindy Nichols, Surveillance Coordinator; Connie Ream, Clinical Administrative Assistant; Joan Schaum, RN, Patient Safety Officer; and Christopher Shih, MD
The patient safety committee at the Regional Gastroenterology Associates of Lancaster (RGAL) is comprised of individuals representing various departments from management, endoscopy and office nursing, infection control and community representation. The RGAL patient safety team worked together and reviewed its patient identification process from the time of registration to discharge through a failure mode and effects analysis, resulting in proper patient identification and consistent labeling of all pathology specimens. Zero errors have been made with specimen mislabeling since this process was implemented.
In 2013, RGAL looked at potential complications for patients with implanted pacemakers and completed several performance improvement projects, including one that resulted in quicker insurance approval turnaround times for patients, which helped reduce the wait times of patients in need of infusions and reduce their out-of-pocket costs. Larger process improvements completed in 2013 included a revision of endoscopy medication management, including drug labeling and coding for look-alike, sound-alike medications. The RGAL staff also made suggestions for improved patient safety that included infection control stations in waiting areas for patients and new chairs for bariatric patient needs.
Maria Stesko, RN, Operating Room
While checking medical device items in carts for packaging defects and expiration dates, Maria found several items missing expiration dates. After investigating other reprocessed items in storage, Maria noticed there were others that did not have expiration dates. A call to the company that supplied the items verified they should have had expiration dates on them as well. All reprocessed items were pulled from the shelves and checked. Also, the company requested the opportunity to do a site visit and review all reprocessed items in the hospital and surgical center for any other items that were missing the expiration information to ensure safety.
Roslyn (Roz) Syrkett, Unit Assistant Substance Detox/Behavioral Health
Roz overheard a patient having a distressing phone call with his mother. Once the patient went back into his room, Roz followed him to make sure he was okay. When Roz arrived in the room, the patient was trying to harm himself. Roz calmed the patient down and ensured he did not harm himself.
Kimberly Wolfe, Transcriptionist Clerk, Imaging Services
WellSpan Gettysburg Hospital
[Submitted with Kelly Crist] Kimberly alerted the appropriate staff to the correct test results for her patient. Kimberly ensured timely and accurate critical test results were given to staff which allowed for immediate and necessary treatment of her patient.
Rachel Wamba Yadrnak, RN, Pediatric Hematology/Oncology
Penn State Hershey Children’s Hospital
As one of the founding members of the Chemotherapy Safety Task Force, Rachel led staff within the department and brought a “closed chemotherapy system” into Penn State Hershey Children’s Hospital. Through her work, this transition into chemotherapy administration systems has decreased the nurses’ exposure and risk of chemotherapy related spills for over three months. Rachel has also worked for two years to develop and implement an annual chemotherapy competency test to monitor the skills of the nurses on the unit. This competency test helps ensure patient safety by promoting consistency and safety in administration, and continued education on different administration techniques.
The Authority will hold the “I am Patient Safety” poster contest each year from May to October. Winners will be announced during Patient Safety Awareness Week. To view the posters from this year’s “I am Patient Safety” contest, visit: www.patientsafetyauthority.org.
Patient Safety Awareness Week is a national observance sponsored by the National Patient Safety Foundation (NPSF) as an education and awareness-building campaign for improving patient safety at the local level. This year’s theme is “Navigate Your Health…Safely.” A patient’s health journey often starts with diagnosis, but experts estimate that up to one in every 10 diagnoses is wrong, delayed, or missed completely and that collectively, diagnostic errors may account for 40,000-80,000 deaths per year in the United States.
In September 2010, the Authority published a Patient Safety Advisory article, “Diagnostic Error in Acute Care” which showed errors related to missed or delayed diagnosis are frequently a cause of patient injury and therefore an underlying cause of patient safety related events. The Authority gives healthcare facilities strategies to decrease diagnostic errors, along with an educational toolkit that contains: a research poster about “Pennsylvania Diagnostic Error in Acute Care,” a diagnostic errors measurement worksheet, a patient education worksheet regarding diagnostic error, a physician checklist for diagnosis, and a DEER taxonomy chart audit tool. Consumer tips titled “Help Your Doctor Diagnose You Correctly” are also available on the Authority’s website at www.patientsafetyauthority.org.