Each year, the Pennsylvania Patient Safety Authority recognizes individuals across the Commonwealth for their commitment and dedication to patient safety through our I AM Patient Safety contest. The Authority received 153 nominations in 10 categories. The nominations described scenarios of teamwork, high reliability, communication, innovation, event reporting, transitions of care, and more. With a section of the Strategic Plan being a focus on the patient, it was exciting to learn that we received our first nomination from a patient's family member.
The participating judges described the nominations as amazing, inspirational, enlightening, inquisitive, empowering, and "eye-opening to the wonders" that occur daily in Pennsylvania healthcare facilities. Judges commented that the stories are "not to be put on a shelf but deserve recognition" and are "impressive examples of how healthcare providers go above and beyond what is expected!" Determining one winner from each category proved difficult, given the numerous wonderful stories submitted.
As you read through the following descriptions, consider how you could apply the solutions they convey at your organization or in your daily practice and think about stories you can nominate for the next I AM Patient Safety contest!
Executive Director's Choice Award
Transport Team: April Murphy, director; Donald Schmidt, manager; and team members Corey Akerly, Michael T. Anderson, Dezmon Beason, Michael M. Birchfield, Miguel A. Claudio, Douglas Davis, Amos L. Dean Jr., Kayla M. Duck, Robert Dunlop, Latiff C. Foster, James T. Gadomski, William G. Galloway, Jason A. Gromley, Alondre M. Hamilton, Peter Hamilton, Shaun M. Jewell, Tyasia L. Jones, Offel Jordan, Aaron Julian, David A. King, Brandy Lowery, Michael D. Newell, Michael W. Olszewski, Jacke Pesante Montalvo, Kaitlyn M. Rowe, Andy Showers, Trevor L. Simpson, Melissa A. Spain, Daniel R. Stevens, Patrick A. Tarasovitch, Matthew Viszneki, Tracy Watson, and Gerald L. Zameroski
The Transport Team at UPMC Hamot places patients first every day! Thirty-three team members work together 24/7 to support clinical staff by moving patients as efficiently and safely as possible—averaging 400 patient moves a day. They also respond to emergency situations and perform chest compressions during patient resuscitations. Implementation of a patient flow application has taken the Transport Team to new heights: Prior to implementation, transporters were decentralized, with each person assigned to a specific department unless needed elsewhere; however, transporters are now dispatched by proximity and priority—resulting in increased efficiency, improved transport times, and cross-training throughout the hospital. They now coordinate multiple destinations into one trip, which has greatly enhanced patient safety and satisfaction. The transport team is trained to better understand the needs of patients with disabilities and is seen as an advocate and resource in this patient population. The team also provides training on the mechanical lift for all new nurses and patient care technicians during employee orientation.
The Transport Team has been responsible for five good catches in the last six months, and in 2018, three transporters received the prestigious Josie King Award for their quick responses to a patient in distress. Day in and day out, the transporters strive to offer the best possible patient experience during transport by maintaining good, open communication during hand-off and treating each patient as if they were a member of their own family.
SUSP Team: Rodney Abney, Maureen Aitken, Jean Albany, Debbie Allmond, Dr. Andrew Beaver, Teresa Bolden, Dottie Borton, Dr. Jack Cohen, Dr. Richard Fine, Denise Grobelny, Julie Hensler-Cullen, Lamont Irvin, Tisa Julius, Rob Levin, Dr. Eric Sachinwalla, Karen Schwartz, Mark Talamona, Tom Trout, and Annette Yerkes
Einstein Medical Center Elkins Park
Surgical site infections (SSI) in the United States are a leading cause of morbidity and mortality among all hospital-acquired infections, and they also are among the most preventable healthcare-associated infections. As such, decreasing SSI has become a priority for orthopedic surgeons around the nation, including those at Einstein Medical Center Elkins Park.
After noting a rise in SSI throughout the Einstein network (2.8% compared to the statewide average of 0.82–0.89%) in 2014, Elkins Park hospital staff established a Surgical Unit Safety Practice (SUSP) committee to address the issue. The multidisciplinary team was tasked with reviewing all processes and procedures around total joint replacement surgery, from patient consultation through rehabilitation. Of particular concern was the timing of administering antibiotics before and after surgery.
The SUSP team used gap analysis and tracers to identify ways to reduce SSI in total hip and knee arthroplasty. In January 2015, they introduced a standardized care bundle to monitor antibiotic compliance and documentation, which includes a checklist that follows the patient from the orthopedic surgeon's office through discharge. The staff was required to sign their initials on this bundle tag beside the tasks for which their department was responsible as they were completed.
The whole staff embraced the new tool, collaborating with the SUSP team to implement it and help refine and improve the process. The impact on patient safety and outcomes was immediate and dramatic. SSI associated with hip and knee arthroplasty fell to 1.2% in 2015, less than 1% in 2016, and 0% in the first quarter of 2017. Following this success, the team has been expanding the tool to other surgical procedures.
Best Use of Authority Resources
Sandra Bach, safety coach champion; Aileen Bojko, safety coach champion and clinical nurse manager; Jadwiga Bobowska, risk manager and patient safety officer; Susan Reichenbach, vice president and chief quality officer; and Tracy Duffy, director of staff development
Good catch reporting is an important component of a facility's patient safety program, as it promotes a culture of safety and enhances employee engagement.
Phoenixville Hospital's Safety Coach Committee routinely reviews and reports the findings from Pennsylvania Patient Safety Authority Advisory articles. Following the September 2017 Advisory article "Promote a Culture of Safety with Good Catch Reports," the committee recommended analysis of hospital data to determine its ratio of good catches to serious events.
They used the Pennsylvania Patient Safety Reporting System (PA-PSRS) harm scores and reporting tool described in the article and calculated good catch-to-serious event ratios, which were below the 2016 statewide ratios. Subsequently, they decided to develop a Good Catch Program and shared their findings with senior administrative leadership, who fully supported the initiative.
The Good Catch Program, which employed the best practices referenced in the Advisory article, debuted in March 2018 during Patient Safety Week. The committee sent emails to staff educating them on the definitions, rationale, benefits, and procedures for good catch reporting. They also engaged staff with online surveys to vote on a logo for the program and take a good catch quiz at the end of Patient Safety Week. Phoenixville's safety coaches promoted awareness and reporting of good catches via the facility's online event reporting system, and they formed subcommittees to administer quarterly Good Catch awards.
In the first quarter following the launch of the Good Catch program, the facility's good catch-to-serious event ratio doubled. Furthermore, analysis of good catches by event type provides important information for process improvement initiatives.
Focus on the Patient
Don Warnick and Peggy (Karish) Leschak
St. Clair Hospital
According to the Centers for Disease Control and Prevention, one person dies by suicide every four hours in Pennsylvania. The Joint Commission lists suicide as the 10th-leading cause of death in America—a higher mortality than traffic accidents and homicides—and estimates 49–65 inpatient hospital suicides occur annually.
Following a near miss at St. Clair Hospital, a multidisciplinary team consisting of emergency department (ED), behavioral health, information technology (IT), and patient safety leads determined that the central point of failure was related to the unavailability of essential patient history regarding previous self-harm and suicidal attempts. Two months later, Hospital Information System Department members Don Warnick and Peggy (Karish) Leschak had developed an IT solution that searches a patient's electronic medical record (EMR) at registration for a history of self-harm and, if found, alerts the admissions team and clinical caregivers in real time. They also added a triage process to the EMR that uses the Columbia-Suicide Severity Rating Scale (C-SSRS) to identify patients who may require close observation based on how their answers to the questions compare to their history.
Data obtained in the first two months after implementation revealed that 100 patients seen in the ED had a discrepancy between the answers on the C-SSRS and their history of self-harm; these patients were given additional assessments and interventions to ensure their safety. Because the new process has been working so seamlessly in the ED, Don and Peggy also will implement these enhancements throughout the inpatient departments as well.
Dr. Robert Gayner, VPMA, St. Luke's University Hospital - Bethlehem, and chief of Nephrology, St. Luke's University Health Network
St. Luke's University Hospital - Bethlehem
Dr. Robert Gayner, chief of nephrology at St. Luke's University Hospital Network, working with a multidisciplinary team, discovered that many patients were being misdiagnosed with acute kidney injury (AKI) or had undiagnosed AKI. As patients' electronic health records often retain diagnoses, these inaccuracies had the potential to cause unnecessary treatments and put patients at higher risk for AKI comorbidities.
Dr. Gayner worked diligently to educate caregivers about the Kidney Disease Improving Global Outcomes (KDIGO) criteria for diagnosing AKI throughout the hospital. Among the many components of this educational outreach, he and the team developed a standardized AKI bundle to help all network inpatient and outpatient providers recognize AKI and identify patients at high risk for AKI when they arrive for a surgical procedure.
Dr. Gayner also issued a set of practice standards to mitigate the risk of AKI, which includes a preoperative nephrology consult for patients depending on their baseline kidney function. He worked closely with the clinical informatics team to automatically identify patients who were at risk for AKI or who had an AKI event in the hospital and trigger clinical decision-making support mechanisms to assure timely and effective care across all disciplines.
These initiatives have been implemented networkwide and have resulted in a 37% reduction in the overall rate of AKI; decreased patient mortality; and improved appropriate diagnosis, treatment, and ongoing management of this patient population.
Shriners Hospitals for Children® – Erie Ambulatory Surgery Center (ASC)
Nurse anesthetist Stephanie LaJohn has a way with children, treating every patient as if they were her own child and quickly winning their trust. She puts even the most anxious children at ease before surgery, reassuring them that she will be with them throughout it and calmly explaining what is going to happen in terms they can understand. She even turns anesthesia into a fun game; for example, she lets kids choose from 20 different flavors for the "anesthesia" and lines their breathing mask with lip gloss so they smell the flavor they picked instead of the anesthetic gases. She gets them excited about going to the operating room to help "blow up her balloon," and as they watch the balloon grow on the anesthesia machine, she often holds them in her lap and sings them softly to sleep. Then when they wake up, she always has a special, parent-approved sweet treat waiting for them. Every day, Stephanie demonstrates how much she loves her patients in her dedication to ensuring their safety, comfort, and peace of mind.
Rose Hall, RT. (R) (CT), Lisa Griffin, RT. (R) (CT), and Dr. Ryan Lee
Einstein Medical Center Philadelphia
Extravasation of intravenous contrast during a computed tomography (CT) scan is a common event that can harm patients, with rare instances of severe complications. Besides the possible complications of contrast extravasation and causing inconvenience to the patient, these events also require additional patient assessment and observation that may impact the workflow of the healthcare team.
During monthly quality improvement meetings, Rose Hall, Lisa Griffin, and Dr. Ryan Lee identified a trend of increased contrast extravasation and decided to design a process to reduce these events. They observed that the rates of contrast extravasation were lower when using a dual-head power injector—used for CT coronary angiograms—rather than the routine precontrast test bolus administered via hand injection. So they implemented a new protocol in May 2016 which requires a power injected 30cc saline bolus through the patient's IV, prior to administering the iodinated contrast. The power injected test bolus is actively observed by the CT technologist at the scanner gantry to look for signs of extravasation; if the saline extravasates, a new IV site of access is attempted. If contrast still extravasates despite a successful saline test bolus, the event is reported by the performing CT technologist, and postcontrast extravasation protocols are followed.
Comparing the rate of contrast extravasation before and after the power injected saline bolus intervention protocol was implemented reveals a 53% reduction in the extravasation rate as compared to the baseline period. The process has provided a safe and effective method to reduce IV contrast extravasation, increase patient safety, improve healthcare staff efficiency, and contribute to better outcomes when performing contrast-enhanced CT scans.
Environmental Services Department
South Mountain Restoration Center
Environmental services is a key line of defense against the spread of bacteria in a healthcare facility, and the 21 staff members of the Environmental Services (ES) Department at South Mountain Restoration Center take their role very seriously. They ensure a clean, sanitary, and comfortable environment for their residents and consistently go beyond their routine responsibilities. For example, they helped implement a new evidence-based practice to prevent healthcare-associated infections, and they took the initiative to ramp up disinfection and cleaning of high-touch surfaces during flu season—which contributed to a 0.04% incident rate of influenza in 2018. After an inspection and consultation from the Infection Control Assessment and Response Program, ES implemented a pilot project to install more alcohol-based hand rub stations to assist in infection control. They installed or repositioned 70 dispensers in one unit and tracked data and reported back to the Quality Assurance Committee. Moreover, some ES staff are certified for direct care and volunteered a combined total of more than 470 hours to assist with residents—just one of the many ways they frequently interact with residents and strive to make them feel at home.
Safety Story (Near Miss or Close Call)
St. Christopher's Hospital for Children
While caring for a patient at St. Christopher's, registered nurse Stacy Green heard strange popping from beneath the child's bed. When she investigated the noise, she discovered a stripped and frayed power cord—which was sparking dangerously. She immediately assured the patient was safe and unharmed, and notified biomedical services and her supervisor. The bed was quickly taken out of service, and she submitted a safety event report, which was shared along with photos of the damaged electrical cord the next day at leadership's daily safety huddle. As everyone grasped the urgency and risk to patient safety, the biomedical and quality department embarked on an audit of every patient bed. Armed with a script to discuss the inspections with concerned patients and families, the inspection team found three more beds with damaged cords and removed them from service. The incident and timely response from Stacy, hospital leadership, quality staff, and biomedical staff prompted a new protocol: The Environmental Service department now inspects patient bed electrical cords when they clean rooms following a patient's discharge. The hospital also reported the incident to the U.S. Food and Drug Administration's Medical Product Safety Network. Subsequently, the bed manufacturer investigated the incident, replaced the frayed cords at the facility, and issued a national alert to their customers with guidance on correct cord storage, inspection, and replacement. Thanks to Stacy's commitment to a culture of safety and timely safety event reporting, hospital leadership was able to take action to prevent patient harm in her organization and possibly others.
Transparency and Safety in Healthcare
Patricia Bambrick, Colleen Arnold, Bev Genetin, Andrew Urbach, Diane Hupp, and the Patient Safety & Quality Department
UPMC Children's Hospital of Pittsburgh
Ten years ago, a medical error in mixing intravenous potassium resulted in a patient's death at UPMC Children's Hospital of Pittsburgh—but now the mother of that patient has nominated the hospital for their efforts to promote safety and minimize or prevent medical errors since her daughter's death. Specifically, she wants to recognize the Patient Safety & Quality Department and Patricia Bambrick, Colleen Arnold, Bev Genetin, Andrew Urbach, and Diane Hupp, and the countless changes they have made throughout the healthcare system to help save lives.
Following that event a decade ago, the hospital not only apologized to the family for the medical error, but also shared their plans to correct the problem so it would never happen again to another family. The hospital implemented numerous safeguards in the pharmacy, established a patient safety and quality committee, and adopted a "just culture" that embraces mistakes as a part of the learning process. Having the courage to admit errors helps the healing process and learning the causes of mistakes provides opportunities to educate staff and design safer systems of care. To foster this culture, the employee website has a section about near misses and catches, and staff members are rewarded for reporting medical errors. Other changes include a patient safety week, hospital rounds, and routine evaluations of systems, as well as an annual Patient Safety Conference. At the first conference, held in memory of the girl who died due to a medical error, her mother was able to share her story publicly—and heal.
Kathryn Farrell, professional practice consultant; George Shafer, nurse manager; and the Therapeutic, Intervention, Presence, and Sanctuary (T.I.P.S.) Team
Penn Medicine Pennsylvania Hospital
Patient safety and patient experience go hand in hand, and structures and processes must be in place to create a cohesive, consistent approach to care—especially at a teaching hospital that is part of a large academic health system, like Penn. So a team determined that the following behaviors were necessary to put patients' needs first:
Therapeutic—convey respect for a person's well-being through words and body language
Intervention—assist or refer to staff who can help
Presence—be mindful of where you are and who you are with
Sanctuary—create an atmosphere that makes patients, families, and staff feel safe
To present these Essential Behaviors for all interactions, known as T.I.P.S., to staff in a fun and impactful way, the team created a professional video highlighting employees and patients describing their care experiences with T.I.P.S behaviors. It includes employees from many departments, from clinical staff to executive leadership—emphasizing that T.I.P.S was a strategic priority. The 10-minute video was shown in 30-minute sessions and is available to all employees on the hospital's intranet. It is reviewed annually and as needed at the unit/department level. It is also available to patients. The T.I.P.S. initiative also included commitment pledges, posters, badge buddies, and story sharing about positive behaviors.
The Essential Behaviors have had a positive impact on the patient experience; the hospital's overall rating rank has increased by 44 points, and by 20 points in its "likelihood to recommend" score. There also has been a noticeable shift in employee behavior toward prioritizing patients' needs.
* Any included numbers and/or results were provided for publication by the recognized healthcare facilities. The Pennsylvania Patient Safety Authority has not independently verified, and bears no responsibility or liability for, these numbers and/or results.