Megan Shetterly, RN, MS
Patient Safety Liaison, Northeast Region
Pennsylvania Patient Safety Authority

The Pennsylvania Patient Safety Authority developed its Patient Safety Liaison (PSL) Program in response to feedback from patient safety officers (PSOs) who requested a greater Authority presence in Pennsylvania’s healthcare facilities. The role of the PSL is to provide guidance, coordinate educational programs, encourage collaboration, and solicit feedback from healthcare facilities that report Incidents and Serious Events under Act 13 of 2002.

As the PSL for the Northeast Region of Pennsylvania, I have met many healthcare professionals whose dedication to patient safety is clearly evident. With so many competing priorities, patient safety is sometimes difficult to accomplish. However, with persistence and creativity, it is effective. Let me share some examples.

Pocono Medical Center’s leadership has endorsed a program it also calls the Patient Safety Liaison Program. One staff member from each clinical department has been given the distinction of being a PSL. This practice extends the reach of the PSO so that the organization has a team of individuals who will identify and report identified patient safety needs. Together, this cohesive group will work to improve patient safety within their organization. Authority representatives provided assistance at the program kickoff meetings in January 2009 and look forward to sharing updates on the medical center’s progress.

Another unique patient safety initiative implemented by some ambulatory surgery facilities (ASFs) involves color banding pediatric patients consistent with the Broselow scale. However, one ASF in the Northeast Region takes the initiative one step further and also bands the pediatric patient’s parent with a duplicate color band that contains the patient’s unique identifiers.

The move to standardize color-coded wristbands, which began in Pennsylvania, is a notable change to improve patient safety, and has spawned a regional, national, and international response. With each facility visit, I communicated how a united system of standardized color bands can affect patient safety. Since this program was actually born out of initiatives in the Northeast Region, most Northeast facilities have adopted this practice. But, I did find one organization that was having some difficulty. Following a recent organizational merger, color-coded wristbands were changed to be uniform throughout the internal system/network. There was some resistance to change to the Pennsylvania initiative’s (The Color of Safety Task Force) color codes, but leadership within the organization and its community patient safety members prevailed. Once the PSO took relevant Authority information to her patient safety committee, there was strong support to initiate change. This was a win for the organization, the community, and ultimately for every patient who is cared for in an organization that has adopted this practice.

Every healthcare facility will evolve at its own pace in regard to the culture of patient safety. Some have made great strides in adopting best practices. My job is to help everyone achieve a culture in which all providers participate in creating a safe environment for patients and an environment in which patients feel comfortable participating in their own healthcare. Each facility I’ve visited has made some relevant change in its systems or processes in order to improve patient safety.

Collaborating with peers about these changes is important. As a PSL, I have personally discussed with PSOs and staff the multiple risk reduction strategies and best practices available to them through the Authority (e.g., Advisory articles, patient safety tools and resources, Consumer Tips, brochures). In response to requests for information and resources—such as medication reconciliation forms, healthcare-associated infection disclosure letters, vendor information on color-coded bands, and intravenous lines for contrast injectors—many PSOs forward facility-specific information to my attention and grant permission to share this with others in need.

It’s a pleasure to be working with such a passionate team of PSOs whose commitment to patient safety is so evident. As the Northeast Region PSL, I look forward to continuing our collaborative efforts in strengthening all Pennsylvania facilities’ patient safety programs. This is just the beginning of a program that will set the stage for bigger and better achievements in the world of patient safety.

Pennsylvania Patient Safety Authority Contact Information

Patient Safety Liaison Program

Franchesca J. Charney, RN, BS, MSHA, CPHRM, CPHQ, CPSO, FASHRM
Director of Educational Programs
Direct line: (717) 346-4569
E-mail: fcharney@state.pa.us

Megan Shetterly, RN, MS
Patient Safety Liaison, Northeast Region
Direct line: (717) 805-7028
E-mail: mshetterly@state.pa.us