Changemakers: Stories That Made a Difference
​​​​​​Pennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also can be tools to trigger change facilitywide—or even nationwide.

Click one of the categories below or type keywords into the search field to find stories of event reports that inspired staff to make changes that improved patient care and safety throughout their hospital.

Featured Story
A safety event involving a discharged patient taking too much of a prescribed medication prompted a facility’s liver transplant and clinical leadership teams to perform a root cause analysis. They identified a significant contributing factor to the event: Each transplant service (e.g., lung, liver, etc.) had a different medication reconciliation process upon discharge. Teams from each transplant service and an interprofessional team (including physicians; nurses; pharmacists; advanced practice nurses; Nursing administration and management; case management; and managers from Regulatory, Quality and Patient Safety) collaborated to establish a standardized process for medication reconciliation upon discharge.

Anesthesia CategoryCardiology CategoryCommunication CategoryContraband CategoryElectronic Health Record CategoryEmergency Department CategoryEquipment CategoryFalls CategoryInfection Prevention CategoryLab CategoryMedication CategoryMonitoring CategoryNeurology CategoryNursing CategoryNutrition CategoryOb/Gyn CategoryOpioids CategoryPediatric CategoryRadiology CategoryRespiratory CategorySepsis CategorySurgery CategoryTimeout CategoryTransplant Services Category