I AM Patient Safety 2019: Transparency and Safety in Healthcare Award

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.

 

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