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They Chased (and Caught) the Unicorn: The Nursing Unit That Reached Zero Falls 



When you lead an organization dedicated to patient safety, you are supposed to say things like “Zero Harm.” It’s easy to say the words but not always so easy to believe—especially when it comes to patient falls—that we can prevent Every. Single. Occurrence.

In fact, I’ve probably given advice like: Set realistic goals for patient falls; you’re never going to get to zero, at least not for very long.

I may have said, “1 in 3 adults over the age of 65 fall each year in the community, so the odds are even higher if you put those same people in the hospital and medicate or operate on them.”

Heck, I’m not over 65 or in the hospital, but I’ve done plenty of stupid things over the years that have caused me to fall.

Thankfully, the nursing staff on 3 South at Fox Chase Cancer Center at Temple University Hospital didn’t care if people like me rationalized why some patients fall.

They said, not on our watch—and proved me wrong.

I selected this team to receive the 2021 I AM Patient Safety Executive Director’s Choice Award. Under the leadership of Lisa Conrad, MSN, RN, clinical manager, and Amy Magagna, BSN, RN-BC, assistant clinical manager, this team took a multipronged approach to fall safety and reached the impressive milestone of 365 consecutive days without a patient fall on their unit, supporting their nursing department’s goal of zero harm.

They caught the unicorn.

Some of their strategies included:

  • Development of staff performance goals
  • Implementation of fall prevention wheels.
  • Patient engagement through education, including their patient learning channel video “Call, Don’t Fall”
  • Designation of unit-based council members to reinforce fall prevention.
  • Installation of a “Fall-Free Day” whiteboard in the unit hallway
  • Frequent communication through their weekly newsletter
  • Commitment to accountability and adherence to their Fall Prevention Standard of Nursing Practice

This team demonstrates how the intersection of organizational responsibility and personal accountability results in outstanding outcomes. Both must be present for success.

The Patient Safety Authority’s I AM Patient Safety annual achievement awards recognize individuals and teams for their personal passion and dedication to keeping patients safer. We received a total of 173 stories of healthcare providers giving their all during some of the most trying times in their careers. Selection was especially difficult this year. Ultimately, we needed to pick the most compelling entries.

The 2021 winners are:

  • Ambulatory Surgery Facility: Allegheny Health Network – Ambulatory Surgery Center Division
  • Conquering COVID-19: Temple University Hospital COVID-19 Team
  • Focus on the Patient: UPMC Carlisle Intensive Care Unit
  • Individual Impact: Kelly Romano, MPH, Director of Infection Control and Patient Safety, Einstein Medical Center Montgomery
  • Improving Diagnosis: Women’s Health Department, Pennsylvania Hospital (two-time award winner)
  • Long-Term Care: Donna Gerofsky, RN, Infection Preventionist, Moravian Manor Communities
  • Nationwide Warriors: Veterans Administration Pittsburgh Health System
  • Physician Offices: Alyssa Parker, Medical Assistant, Lehigh Valley Physician Group, LHVN ExpressCare–Fogelsville
  • Safety Story: Brianna Thompson, PharmD, Clinical Pharmacy Specialist, UPMC St. Margaret
  • Transparency and Safety in Healthcare: WellSpan Health Continuing Care Services Team
  • Executive Director’s Choice Award: Lisa Conrad, RN, MSN, Clinical Manager; Amy Magagna, BSN, RN-BC, Assistant Manager; and the Third Floor Surgical Oncology Nursing Team, Fox Chase Cancer Center at Temple University Hospital

We thank these and all nominated individuals for their dedication to making patient care safer for all of us.                     

About this blog

Regina Hoffman serves as the  executive director of Pennsylvania’s Patient Safety Authority and editor-in-chief of Patient Safety, its award-winning journal.  Ms. Hoffman was recognized by Becker’s Hospital Review as one of the top 50 experts leading patient safety in both 2018 and 2020. This blog serves as a source for her to share her insights in patient safety and leadership with Pennsylvania’s healthcare leaders.



***​ The views and opinions expressed at or through this blog are the opinions of the author alone and may not reflect the opinions or positions of the Patient Safety Authority or the Commonwealth of Pennsylvania, nor do these views represent in any way medical or legal advice. ​ 

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