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
Computer Keyboard
While changing the directions for insulin, a nurse identified that the “No Print” button in her hospital’s electronic medical record (EMR) was sending a prescription (Rx) cancellation to the pharmacy. When the EMR system went live, using the “No Print” button to adjust directions without sending a new Rx to the pharmacy had been a common practice because the patient did not need a refill, and since pharmacies were not yet integrated with the EMR, they had not been receiving cancellations. However, as more pharmacies integrated with the system, cancellations from using the “No Print” button began to occur more often. This was a major safety issue because the patient medication list needs to reflect current dosage orders accurately.​

The nurse recognized the potential for a very serious patient medication error due to the EMR constraints and took appropriate elevation measures. In response, the hospital placed an EMR optimization ticket and held many discussions to find a better solution to this issue. The nurse contributed to these focused discussion groups, advocating for patients and their safety, and after many months and much collaboration they decided to remove the “No Print” button and use the “Edit/Change” button instead. They also created a smart phrase in the EMR to send the pharmacy instructions that the directions have changed, but a refill is not necessary.​​

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