The Pennsylvania Patient Safety Authority held its annual I Am Patient Safety contest to recognize individuals and groups taking action to positively impact patient safety. The contest provides an opportunity to showcase the great work being done in Pennsylvania healthcare facilities and reward the people involved. We received more nominations this year than ever before. As one of the judges, I personally read all 184 submissions and was impressed by the evident level of dedication and resulting impact on patient safety.
The judging panel, composed of an Authority board member, executive and management staff, and a patient community member, evaluated submissions using the following criteria: the person or group demonstrated (1) a discernible impact on patient safety for one or many patients, (2) a commitment to patient safety, (3) a strong patient safety culture present in the facility, and (4) initiative. Winners were awarded with a plaque, certificate, and recognition pin from the Authority. Their photos and patient safety efforts were highlighted on posters that could be displayed within their facilities. Winners and healthcare facility representatives were also invited to attend the March 2017 Authority Board of Directors meeting and a luncheon to meet Authority board members and staff. I want to thank everyone who participated in the contest. It is always a challenge to narrow such an impressive group of nominations down to just a handful of winners.
The next round of nominations begins May 1, 2017. Please take the time to acknowledge the patient safety stars in your facilities by nominating them for this contest. The Authority board members and staff appreciate the time you have taken to tell us about your colleagues’ efforts to improve patient safety in Pennsylvania.
Thank you, again, to all who participated in the I Am Patient Safety contest. Please join me in congratulating the winners for their commitment to patient safety.
I am Patient Safety: 2017 Winners
The individuals and groups recognized for the I Am Patient Safety contest and their achievements are grouped by name of facility.*
* Any included numbers and/or results were provided for publication by the recognized healthcare facilities. The Pennsylvania Patient Safety Authority has not independently verified, and bears no responsibility or liability for, these numbers and/or results.
Trisha Patel, PharmD, BCPS, BCCCP
Critical Care and Infectious Disease Pharmacist
Cancer Treatment Centers of America® at Eastern Regional Medical Center
A patient with cancer was ill with signs and symptoms that suggested a urinary tract infection. Trisha Patel, a critical care and infectious disease pharmacist, went beyond her standard inpatient duties to review the outpatient’s urine test results. Trisha, who works to ensure that patients are on the right antibiotics for their particular disease, noticed the patient was infected with a harmful, multidrug-resistant bacterium. She called the infectious disease consultant and the patient was admitted to the hospital to receive necessary intravenous (IV) antibiotics.
Trisha’s attention to detail and quick identification of the bacteria prevented the patient from developing a worsening infection.
Melissa Hewitt, Clinical Nurse Manager, Registered Nurse, Certified Neonatal Intensive
Care Nursing, MSN
Arlene Stonelake, Registered Nurse, Certified
Meghan Mahoney, Registered Nurse, Certified
Labor & Delivery Department
Einstein Medical Center Montgomery
A manufacturer changed the packaging of a medication for IV treatment, and the new bag looked very much like another medication. As nurses in the Labor & Delivery department, Melissa Hewitt, clinical nurse manager; Arlene Stonelake, registered nurse; and Meghan Mahoney, registered nurse worried that the wrong medication could be given to patients. After trying numerous solutions, the group and hospital pharmacy changed procedures so that instead of using two sizes of IV bags, the medication with the new packaging is prepared only in a 500 mL bag, the department’s only bag of that size.
The team’s persistence led to a safer process for distinguishing IV medications.
Rose Hall, RT (R) (CT), and her team in the CT Scan Department
Einstein Medical Center Philadelphia
Although important in evaluating patients, computed tomography (CT) scans increase patient exposure to dangerous radiation. Rose Hall, supervisor of the CT Scan Department, and her team made it their priority to reduce the amount of radiation used in scans. They worked with radiologists to implement new protocols, and new scanning technology was introduced.
Because of these changes, the image quality of CT scans improved and average radiation exposure was cut in half. Einstein ranked in the top 17th percentile of participating providers in the American College of Radiology Dose Index Registry.
Andrew Klee, Infection Control Practitioner
The Healthcare Acquired Infections Team
Guthrie Robert Packer Hospital
Good hand hygiene is important in protecting patients from healthcare-acquired infections (HAIs) that healthcare workers can unintentionally spread. The HAI Team, under infection preventionist Andrew Klee, convinced the hospital to install an electronic hand-hygiene monitoring system. Any employee who routinely enters patient rooms wears a monitoring badge, and handwashing compliance is posted for all to see. The team also collaborated with the Environmental Services Department to use an ultraviolet-light robot to disinfect operating and intensive care unit rooms.
The results were favorable—the oncology unit saw a threefold decrease in patients infected in the hospital with the harmful bacterium Clostridium difficile.
Paul Karlin, DO, Medical Director of Critical Care Unit (CCU) and Division Chief for Pulmonary Medicine
Jeanes Hospital performs case reviews for each patient death, to improve patient safety and quality of care. Dr. Karlin performs the lion’s share of these case reviews. He looks to improve clinical care, foster respect and communication among providers, provide patient dignity, and enhance family-member relations. He is frank about opportunities for improvement but does not place blame.
His efforts, as architect of a new departmental structure and captain of the ship, have prompted physician and staff education, policy and process revisions, and practice changes that support better patient outcomes.
The Pain Center of OSS Health
A large team of nurses in a pain-management procedure center needed to consult about cases while still maintaining patients’ privacy. To achieve this, the center implemented among the staff use of two-way wireless communications, with devices that have a microphone and a single earpiece.
Recently, a patient in the procedure room fainted while being helped from the procedure table to a wheelchair. The procedure room nurse used her wireless device to call for assistance. Multiple staff members responded. Thanks to the wireless system, the post-op nurses were also aware of the situation and notified the family and gathered the supplies needed to properly care for the patient.
Wannetta Love, Registered Nurse, CCRN
Intensive Care Unit
As a registered nurse in the intensive care unit (ICU), Wannetta (Neadie) Love observed two patients who each had an endotracheal tube. One patient had a facial pressure injury associated with the endotracheal tube, while the other patient did not. She investigated and found that the unaffected patient had been transferred from another facility that used a special holder to reduce pressure-injury development. Love championed the use of these holders.
Because of her efforts, the hospital decided to purchase the pressure-reduction devices, which are now used in the ICU. No facial pressure injuries have occurred since.
Erin Madden, Patient Care Assistant - Nursing 4S PCT
As a patient care assistant, Erin Madden was helping a patient into bed. She had made sure the bed’s wheels were locked, but during the patient’s transfer, the bed shifted away. Fortunately, the patient did not fall. The bed was repaired. But Erin remained concerned and raised the issue during one of the unit’s daily safety huddles. The concern was relayed to hospital leadership. It was discovered that even with wheels locked, nearly 60% of the beds on the unit were unstable.
This finding led to a hospital-wide assessment and repair of the wheel locks on all beds in the facility, lessening patients’ risk of falling.
Ashley Hartzell, Registered Nurse
Babette Rudick, Registered Nurse
Lisa Swenson, BSN, RN, ONC
Jacqueline Brown, Medical Assistant
Tina Frank, MHS, BSN, RN
Teresa Diez, Certified Registered Nurse Practitioner
Surgery Optimization Clinic
A surgery optimization clinic was established by Tina Frank, MHS, BSN, RN, with the help of her team Teresa Diez, CRNP; Lisa Swenson, BSN, RN, ONC; Ashley Hartzell, RN; Babette Rudick, RN; and Jacqueline Brown, MA. They collaborate with healthcare providers inside and outside the hospital to coordinate care, looking at “the whole person” through one-on-one education and support before surgery. These programs include screenings related to pain, smoking, sleep apnea and alcohol use, weight management and dietary practices, and “prehabilitation” to improve mobility.
Endoscopy Department and Infection Prevention and Control Staff
Recently, gastrointestinal professionals were shocked to learn that nationally, an antibiotic-resistant organism was being spread to patients through endoscopes that were contaminated, even after proper cleaning (the scopes have crevices that shelter bacteria). The PinnacleHealth endoscopy leadership, the endoscopy team, and the infection control department devised a plan to mitigate the risk to patients. The endoscopy team embraced the new disinfecting process, even though it takes more time.
After reorientation and education, the Endoscopy Department staff process endoscopes beyond professional standards.
Renu Joshi, MD, Medical Director, Endocrinology
NP Inpatient Endocrinology Service
When patients with diabetes are hospitalized, controlling their blood glucose levels is difficult. Hospital workers may not have expertise in managing glucose levels. Additionally, the patient is seen by multiple practitioners—each treatment can affect a patient’s blood glucose levels. As medical director for endocrinology, Dr. Joshi heads a Diabetes Clinical Initiative and championed the creation of a Nurse Practitioner Inpatient Endocrinology Service. This multidisciplinary service improves knowledge among nonspecialist staff and provides education, advice, and support to clinical staff, patients, and families.
Because of this program, diabetic patients’ hospital stays are shorter and they have fewer surgical-site infections than before.
Donna Miller, Nurse Manager
Jessica Radicke, Administrative Charge Registered Nurse
Marissa McMeen, Infection Control Practitioner
Bone Marrow Transplant Unit
Thomas Jefferson University Hospital
Concerned about the number of central line–associated bloodstream infections (CLABSIs) in the Bone Marrow Transplant Unit, Donna Miller, nurse manager; Jessica Radicke, administrative charge registered nurse; and Marissa McMeen, infection control practitioner made positive changes. Protocols were altered to limit who could change central-line dressings, and staffing was adjusted to cover this task. They introduced a medical manikin so nurses could practice and demonstrate accessing the central line. Senior leadership recognized and celebrated the team’s success.
Since the action plan was implemented, the unit has experienced just one CLABSI in 15 months.
Quality Based Improvement Resident Teams
Department of Surgery
Thomas Jefferson University Hospital
Recognizing the importance of quality and safety education, surgical residents at Thomas Jefferson University Hospital established the Quality Based Improvement Resident Teams (QBIRT) initiative. Under QBIRT, residents have researched, developed, and launched programs to reduce harm and improve the quality of care for surgical patients. They have led projects that have resulted in reducing surgical site infections and catheter-associated urinary tract infections and safer insertion of feeding tubes. With one hospital-wide QBIRT initiative, residents analyzed data and created a “risk score” to help predict postoperative respiratory failure in an effort to intervene earlier and prevent these complications.
Through advanced analytics, best practice implementation, team integration, and innovation, the residents of QBIRT have made a significant difference in patient care and surgical outcomes.
ICU Service Partners
Infectious Disease Practitioners
UPMC Susquehanna’s Williamsport Regional Medical Center
A team of intensive care service partners, infectious disease practitioners, and a professional development specialist analyzed every CLABSI in the ICU. They aimed to reduce CLABSIs. The expectation was set that staff would wear a mask and use a sterile drape whenever accessing a central line (to give medications or draw blood). The professional development specialist conducts competency checks and infectious disease practitioners monitor compliance with infection-control practices.
After achieving 572 days without a CLABSI, these partners continue with the goal of zero CLABSI for patients in the ICU.