I AM Patient Safety 2020: Innovation Award

Innovation Award Winners from WellSpan Health standing around a patient photo

The Patient Safety and Organizational Learning and Development Departments: Dr. MaryEllen Pfeiffer, Mary Zeigler, Melissa Heath, Melinda Jeffries, Nancy Nicholas, Suzanne Gervase, Karla Heberlig, and Duane Patterson

WellSpan Health


For the annual WellSpan Health Quality Forum, where 500 team members from the integrated health network gather to showcase various quality improvement and patient safety projects, this team created a unique workshop breakout session: a patient safety escape room.

The escape room featured an unfolding narrative of a 66-year-old Hispanic woman, Marina, who suffered from rheumatoid arthritis, diabetes, kidney disease, and anemia. She had fallen down the steps on the front porch and presented to the ED with back pain. She was found to have an acute compression fracture of her lumbar vertebra and a urinary tract infection. She was a fall risk and did not have vascular access, requiring a central venous catheter to be placed for administration of IV antibiotics and pain medicine.

For the exercise, 150 participants were divided into tables of eight. As the timer counted down from 30 minutes, the groups worked through a series of puzzles, guided by a trained facilitator with props and a laptop. These challenges incorporated videos, pictures, and book ciphers. For example, filling out a crossword puzzle to simulate identifying and removing self-harm elements from Marina's ED room, and assembling a 24-piece jigsaw puzzle of a blueprint of the medical unit to find an unoccupied bed close to the nurse station.

After a team completed all the tabletop exercises, they escaped the large conference room into a smaller room where they ran through a high-fidelity simulator showing Marina was unarousable, bradycardic, and barely breathing. The medication administration record uncovered two doses of narcotics in close succession, and naloxone was the antidote that revived the patient.

Eight teams completed all six puzzles. Evaluations showed more than 95% of participants rated the session as excellent or above average. Everyone walked away feeling inspired by the experience and with a new passion for patient safety.


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