Pa Patient Saf Advis 2011 Mar;8(1):44.
Authority Recognizes Departing Chairperson

Ana Pujols-McKee, MD, provided leadership and vision to the Authority in broadening its mission.
Ana Pujols-McKee, MD, provided leadership and vision to the Authority in broadening its mission.


Ana Pujols-McKee, MD, the chairperson of the Pennsylvania Patient Safety Authority’s Board of Directors, resigned her position to begin a new chapter in her career as executive vice president and chief medical officer of the Joint Commission in Chicago, Illinois. Dr. McKee will be greatly missed, but she has left an indelible mark on the Authority by helping us broaden our activities beyond data collection and written guidance. When Dr. McKee became chair in May 2006, the Authority was in its second year of collecting patient safety event reports from Pennsylvania’s healthcare facilities. That same year, the Authority won a prestigious John M. Eisenberg Patient Safety and Quality Award for its data collection efforts and the Pennsylvania Patient Safety Advisory—a quarterly academic journal containing data analysis and risk reduction strategies for Pennsylvania healthcare facilities based on the events they’ve submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS).

As patient safety officer (PSO) at Penn Presbyterian Medical Center, Dr. McKee understood the importance of ensuring that collected patient safety event data was used to inform providers and that the Advisory information was actually implemented and not just read. She realized the Authority was in a unique position to reach out to the Pennsylvania healthcare community through education and collaborative efforts.

As chair, Dr. McKee helped lead the board in developing a strategic plan for the Authority to be implemented during the next three to five years. In May 2007, the board adopted a strategic plan with eleven initiatives. One of the initiatives was the Patient Safety Liaison (PSL) Program. Through this program, healthcare facilities in every region of the state have a PSL assigned to them. The PSL acts as a consultant in helping facilities receive the latest patient safety information and making facility PSOs aware of what resources are available to them to implement process changes in their facilities aimed at reducing medical error.

Another strategic plan initiative is to have the Authority work collaboratively with facilities and other organizations on specific patient safety issues. Currently, the Authority is working with facilities in collaboratives aimed at eliminating wrong-site surgery, reducing harmful patient falls, and eliminating healthcare-associated infections. Recently, the collaborative to reduce blood specimen mislabeling errors in the Northeast ended. Preliminary results show these facilities realized a 37% drop in mislabeling errors. More details will be forthcoming in the Authority’s 2010 Annual Report and June 2011 Advisory. The Authority is also working in a collaborative with the Hospital and Healthsystem Association of Pennsylvania aimed at educating boards of trustees and executives in hospitals to ensure they understand that patient safety is a fiduciary responsibility.

Also in line with the strategic plan, the Authority developed and implemented the Pennsylvania Patient Safety Knowledge Exchange (PassKey). PassKey is an online community website for Pennsylvania’s PSOs, providing a knowledge library and a forum for discussing solutions and strategies for reducing medical errors. The website was developed to enhance the working relationship between Pennsylvania’s healthcare facilities to improve patient safety.

During Dr. McKee’s tenure, the Authority made reporting and reducing healthcare-associated infections (HAI) an important initiative. The Authority developed and now maintains the only statewide repository of HAI reports for nursing homes in the country. All nursing homes now have access to analytical reports that assist them in addressing HAIs.

Recently, the Authority received the prestigious Cheers Award from the Institute for Safe Medication Practices for its dedication to reducing medication errors. As Dr. McKee begins a new chapter in her career, I have no doubt more awards and success stories are in the future.

As executive director of the Authority and on behalf of the Authority staff, I wish her well and have a deep appreciation for the leadership and passion she has provided to the Pennsylvania Patient Safety Authority in its quest to analyze, educate, and collaborate to improve patient safety.

Michael C. Doering, MBA
Executive Director
Pennsylvania Patient Safety Authority

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