Authors
Michael C. Doering, MBAExecutive DirectorPennsylvania Patient Safety Authority
Introduction
The Pennsylvania Patient Safety Authority held its annual
I Am Patient Safety poster recognition contest during the last several months to recognize individuals and groups within Pennsylvania’s healthcare facilities who have demonstrated a personal commitment to patient safety. The
recognition poster contest is held each year, with posters delivered to facilities in time for Patient Safety Awareness Week, March 8 to 14, 2015. The contest helps patient safety officers promote progress being made within their facilities to improve patient safety. As one of the judges for the competition, I am impressed by the number of patient safety improvements individuals and groups are making throughout Pennsylvania. This year, we had three times as many nominations as last year, so judging them was a bit more difficult, but even more enlightening.
I want to thank everyone who participated in the contest. Keep an eye out for that person or group you think should be recognized for their patient safety efforts next year, and nominate those individuals or groups for the next poster recognition contest beginning in May. I appreciate the time taken to tell us what your colleagues are doing to improve patient safety in Pennsylvania.
Several Authority board members and management staff comprised the judging panel. The panel judged submissions upon the following criteria: the person or group (1) had a discernible impact on patient safety for one or many patients, (2) demonstrated a personal commitment to patient safety, and (3) demonstrated that a strong patient safety culture is present in the facility. Bonus points were awarded for submissions that demonstrated initiative taken by an individual.
Winners received their photos and patient safety efforts highlighted on posters that can be displayed within their facilities. They also received a certificate and an I Am Patient Safety recognition pin from the Authority. Winners were invited to attend the March 2015 Patient Safety Authority Board of Directors meeting for lunch and to meet the Authority board members and staff. I Am Patient Safety: 2015 Winners
The individuals and groups recognized for the I Am Patient Safety poster contest and their achievements are as follows (in alphabetical order by name of facility):
Lorena Romero-Prato, Admissions Office Secretary
Lisa Sarnowski, RN, CEN
Jodi Celender, Monitor Tech, Nursing Assistant II
Allegheny Health Network, West Penn Hospital
A patient was trying to call her doctor but accidentally reached a West Penn Hospital voice mailbox. She left her phone number but not her name or address, stating she was in pain and thought she was having a heart attack. Lorena Romero-Prato heard the distress in the patient’s voice and tried to call her back, but there was no answer. Lorena dialed 911 to get emergency medical services to respond. The call center, however, was unable to help without a name or address. Lorena then called the West Penn Hospital Emergency Department (ED) to ask for help. She reached Lisa Sarnowski, RN, who knew there was a way to look up the phone number of a person without the name, but she wasn’t sure how. Lisa called Jodi Celender, a nursing assistant and monitoring technician in the ED. Lisa and Jodi were able to find the caller through a reverse phone number search. Once they identified her, they contacted 911 and emergency medical services were dispatched. The ambulance reached the patient and brought her to the ED for further evaluation.
David Ezdon, PharmD, Clinical Pharmacist
Einstein Medical Center Montgomery
As a clinical pharmacist, David has focused on improving patient care by building a culture of patient safety. He has worked with the hospital’s falls committee and natural sleep initiative team to reduce patient falls due to certain medications. He was also instrumental in improving patient safety in the neonatal intensive care unit by demonstrating how staff can use electronic ordering plans efficiently, rebuilding the unit’s pump libraries to maximize safety software, and educating staff pharmacists on properly compounding medications. David has also led the effort to establish an antibiotic stewardship program to minimize the use of antibiotics and reduce Clostridium difficile (C. diff) rates. He also developed electronic order pathways to help prescribers avoid harmful drug interactions when ordering new oral anticoagulants. David’s efforts to improve gaps in Einstein’s communication systems have encouraged all who work with him to seek his expertise and recommendations.
Tom Miller, MLT, ASCP, Medical Laboratory Technician
Einstein Medical Center Montgomery
As a medical laboratory technician at Einstein Medical Center Montgomery, Tom discovered why blood draws resulted at the bedside of premature infants often show different results for glucose levels than specimens that were resulted in the lab. He spent many hours investigating the issue when neonatal intensive care unit (NICU) staff noticed that the blood results for infants were markedly different for glucose when resulted at the bedside, than when resulted in the laboratory. Tom found that since an infant’s red blood cells are more active metabolically, they consume more glucose compared to the same red blood cells in adults. This difference means that an infant’s glucose level will be higher when resulted at the bedside as compared to when resulted in a laboratory. Because of Tom’s persistence, infants in the NICU are safer and are spared from unnecessary blood draws.
Nora Ramirez, Environmental Services Worker
Einstein Medical Center Montgomery
As a member of the environmental services team, Nora shows her dedication to patient safety over and over again in the way she cleans each patient’s room. Always compliant with isolation precaution requirements, her cleaning process is so thorough that every surface in the patient’s room is wiped and disinfected every time. Nora understands the importance of her role in killing multidrug-resistant organisms (MDROs) to prevent healthcare-associated infections (HAIs) at Einstein Medical Center Montgomery. Her surfaces pass Einstein Medical Center’s infection prevention monitoring program 100 percent of the time. Nora’s cleaning methods are a model for our infection prevention control team.
Emily Coon, RN, BSN, Emergency Department
Fulton County Medical Center
As a nurse in the emergency department (ED), Emily works to improve the delivery of care to her patients. Part of this effort includes using the electronic medical record system to ensure her patient’s medications are updated regularly with outside pharmacy information. The medication reconciliation process can be time consuming, but Emily recognized the value in obtaining a patient’s medication list and comparing it to external pharmacy records. She recently cared for a patient in the ED who had a strange set of symptoms, given the patient’s age and medical history. While performing medication reconciliation, Emily noticed the patient recently had a prescription filled for a class of drug which was not consistent with her medical history. She questioned the patient thoroughly, which took a significant amount of time. After reviewing the medications over the phone with the patient’s family, it was found that the patient received a prescription that was not intended for her. Emily’s persistence in this matter helped identify the cause and subsequent treatment of this patient’s symptoms.
Elizabeth Martin, RT(R)(VI), RCES
Lancaster General Health
As a radiologic technologist, Beth volunteered to serve as the electrophysiology and pacing department’s radiation safety officer. Her goals were to reduce patient radiation exposure and increase the safety of fellow staff members and physicians. Beth worked closely with the x-ray equipment vendor, staff and physicians to identify action steps to reduce radiation exposure for all. The team identified several key strategies, including, but not limited to: partnering with the x-ray equipment vendor to establish the lowest standard equipment settings that still provided accurate images; providing education and training opportunities for staff; developing a radiation time-out to alert the physician when 30 minutes of fluoroscopy time was reached; using Gafchromic film to measure radiation exposure; and developing a database to track patients’ exposure information. A post-implementation study shows a 44 percent decrease in radiation exposure to patients from calendar year 2011 to 2012. Beth continues to educate physicians and staff about the dangers of radiation exposure and the importance of compliance with the guidelines established through this project.
Kathleen Cochrane, RN, Neonatal Intensive Care Unit
Lehigh Valley Hospital
While checking medication stock in Lehigh Valley Hospital’s neonatal intensive care unit (NICU), Kathleen Cochrane noticed a difference. The vaccine was not the usual type of hepatitis B vaccine that was normally stocked. Kathleen called the pharmacist to question it. The pharmacist came to the NICU to check the vaccine and determined that it was not the correct medication to be administered to babies. Kathleen’s attention to detail may have prevented a serious patient safety event.
Gloria Mazzie, RN, Behavioral Health Unit
Lehigh Valley Hospital
After the hospital purchased paper bags with handles to store patient clothing, Gloria discovered that a patient in the hospital’s behavioral health unit had tied together the bag handles to use as a belt. It was determined that this belt was strong enough for a patient to cause harm to himself or another patient. Gloria’s quick response to this concern initiated a search to find a bag that would be safer for patients to use in the behavioral health unit. Her dedication to patient safety may have prevented a serious patient safety event.
Christine Reesey, RN, Float Pool Center for Critical Care
Lehigh Valley Hospital
While reviewing a chest x-ray, Christine noticed that the patient’s partial denture plate had slipped out of place and was lodged in his throat. She noted this before it was seen by the radiologist. Christine notified the medical team and the plate was removed. Ten days later, while caring for another patient, she noticed the physician had placed an order for insulin that was much higher than what the patient had been receiving. Christine contacted the physician to question the order and obtained an order for a decreased dose. Her continual attention to detail may have prevented two potentially serious patient safety events.
Jolene Barbazzeni, RN, Stroke Coordinator
Penn Highlands Healthcare (DuBois)
Jolene leads the “Good Catch” committee, which recognizes Incidents or near-miss events that could have caused harm to patients but did not actually occur. She has also personally had many “good catches” that prevented patient harm. Most recently, Jolene’s effort was chosen as the “Good Catch of the Month” when she prevented a potential wrong-site surgery. A patient needed surgery on the right side of his neck to prevent a stroke. Jolene noticed the wrong side was documented in his record. She immediately notified the patient’s caregivers, and the patient received the proper surgery.
Tammy Angeletti, MS, RRT-NPS, RN, CPFT, AE-C
Clinical and ECMO Specialist, Department of Respiratory Care
Penn State Hershey Children’s Hospital
While providing care for a child with a tracheostomy tube, Tammy recognized a variable connection issue between the oxygen delivery device and the tracheostomy tube. She worked with a manufacturer to develop a device that would provide a standard connection, eliminating any variation to the oxygen set-up.
Marybeth Lahey, RN, BSN, Nurse Manager of the Well Mother and Baby Unit
Susan Meyers, MSN, RNC, CPNP-PC
Pennsylvania Hospital
In early 2012, Marybeth and Susan were made aware of significant safety concerns related to infant falls at the Pennsylvania Hospital. Infant falls were reviewed from March 2012 to March 2013. During this time, 10 infant falls occurred, translating to a rate of 21.5 infant falls per 10,000 births. Marybeth and Susan did an exhaustive literature search on infant falls and found little information published. As educators for Pennsylvania Hospital, Marybeth and Susan developed interventions within the facility that included: training all food service and environmental services staff about infant falls prevention and how to intervene when moms are noticed in a sleepy state; educating all nurses and physicians about the need for increased vigilance; recruiting physicians as champions to prevent infant falls; giving moms two hours of quiet time in the afternoon so they could sleep; revising a safety contract to inform parents about the risks involved in caring for an infant while fatigued; developing a Good Catch log to capture opportunities for further education; and developing a falls debriefing process. As a result of these implemented interventions, Pennsylvania Hospital experienced an 88 percent reduction in infant falls.
Karen Barbieri, RN
Cindy Valerio, RN
Progressive Care Unit/Telemetry
Phoenixville Hospital
Cindy noticed that a patient with heart failure had been discharged without his prescriptions after finding them on the discharge desk. Cindy voiced her concerns to her unit coordinator, Karen Barbieri, who agreed the patient was at risk for heart failure complications if he didn’t have his prescriptions. Karen called the patient and found he was not able to determine what medications he had at home. The patient had gained two pounds in a short period of time, which is a complication of heart failure. Karen recognized this patient was in danger at home and called medical home care services to help the patient. She also called the primary care physician to get the patient his needed prescriptions. During a daily safety call, this event was discussed and all staff used it as a learning opportunity.
Lisa Connolly, RN, Medical Surgical Unit
Phoenixville Hospital
As a medical--surgical nurse, Lisa was caring for a patient following joint replacement surgery. Upon reviewing her patient’s electronic medical record, she noticed the surgeon had ordered two specific blood thinner medications for him to take after surgery—one was the blood thinner he had taken at home before surgery and the second was another medication. Lisa immediately questioned why two of the same medications were ordered for her patient and held both doses until further review. The attending physician was notified, and new medication orders were obtained. It was discovered that both the surgeon and pharmacist received a clinical alert within the electronic medical record, but both ignored the alert. As a result of Lisa’s questioning and subsequent follow-up to verify and validate the medications, the patient did not receive duplicate medications. The lessons learned from this near-miss event were shared at unit-based and leadership safety huddles.
Conclusion
Thank you, again, to all who participated in the I Am Patient Safety poster recognition contest, and join me in congratulating the individuals recognized for their efforts to improve patient safety in Pennsylvania’s healthcare facilities. Your commitment to patient safety does not go unnoticed.
