I AM Patient Safety Transparency in Healthcare Award

2022 IAPS Transparency &  Safety Award Winner UPMC Carlisle and Central Pennsylvania Hospitals

Left – Vanessa Elliott, MD, chief of Urology; R. Scott Owens, MD, both of UPMC Urology of Central PA 

Center – Mary Lou Mortimer, senior director, nursing education and research; Lauren Winters, RNC-OB, senior system analyst

Right –  Front row: Erin Wilfong, patient safety specialist; Mandy Martin, clinical director of nursing; Joye Gingrich, CNO; Elena R. Dailey, MD, hospitalist medical director

              Back row: Andrea Strick, nurse educator, Emergency Department; William Kauffman, MD, VPMA; Tracey Rush, unit director, Emergency Department; Lynn Leighton,                                  director, Patient Safety; Rupen Modi, chair, Department of Emergency Medicine; Helen Houpt, librarian

​Nursing Leadership and Education, Physicians, EPIC Team, Patient Safety, and Library Staff
UPMC Carlisle and Central Pennsylvania Hospitals

The review of an event involving an adverse patient outcome related to continuous urinary bladder irrigation resulted in the formation of a collaborative group involving Epic staff; Nursing leadership; Nursing Education; Patient Safety; and emergency department (ED) physicians, hospitalists, and urologists.

The library staff assisted in identifying several articles that informed the creation of the continuous urinary bladder irrigation order set. Nursing staff involved in this event were key to identifying opportunities to improve the process; although there was an existing nursing policy and procedure related to continuous bladder irrigation, it lacked specificity that could be achieved through the creation of order panels in the ED and complementary order sets for inpatient units.

The order set provides specific instruction on the appropriate size catheter to select for manual and continuous bladder irrigation; the need to manually irrigate the bladder to remove all clots before beginning the continuous urinary bladder irrigation; the necessity of strict intake and output monitoring to ensure that the amount returning from the bladder is equal or greater than the amount of irrigant solution placed in the bladder; when to call the ordering physician for problems encountered with continuous urinary bladder irrigation; and medications that can be used to minimize symptoms patients experience with continuous bladder irrigation.

After learning that many of the ED nurses involved in this event had limited experience with urinary bladder irrigation, decisions were made to incorporate content about urinary bladder irrigation into the emergency nursing education and other nursing education courses as appropriate and to revisit this procedure for maintenance of knowledge and skills on an annual basis. Efforts were also focused on ensuring consistent documentation of what amount of solution was placed in the bladder and the amount expelled. 

A presentation by a staff urologist, “Catheters and Continuous Bladder Irrigation,” is also available for viewing. It reviews information on proper selection of urinary catheters; provides tips on the insertion of a urinary catheter in men and women; and reviews manual and continuous urinary bladder irrigation, including how to properly do both and manage problems you may encounter with the procedure.

​Although this event happened at UPMC Carlisle, the interventions taken were implemented across all Central Pennsylvania hospitals in the UPMC health system. The event was discussed in forums at each of the hospitals, and it was shared with staff in the Patient Safety Newsletter to show how transparency and collaboration can result in system improvement for patient safety.



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