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The Pennsylvania Patient Safety Authority Recognizes Pennsylvania

Healthcare Workers Committed to Patient Safety

HARRISBURG, Pa., March 3, 2014 /PRNewswire-USNewswire/ -- Continuing

efforts to encourage each healthcare worker in Pennsylvania's

healthcare facilities to make a personal commitment to patient safety,

the Pennsylvania Patient Safety Authority has featured 10 individuals

and groups on posters who have committed themselves to patient safety

within their healthcare facilities. The posters were developed for

display during National Patient Safety Awareness Week March 3-9.

In the last few months, the Authority held its first "I am Patient

Safety" poster contest to highlight individuals and groups who have

made a personal commitment to patient safety. The contest coincides

with a campaign the Authority began last year for National Patient

Safety Awareness week in which the Authority developed posters with a

checklist of what healthcare personnel can do individually to promote

a culture of safety and/or improve patient safety in their facility.

"Patient Safety Awareness Week is a great time for the Authority to

recognize those individuals and groups within Pennsylvania's

healthcare facilities who have taken the steps necessary to improve

patient safety within their facility," Mike Doering, executive

director of the Pennsylvania Patient Safety Authority said. "The

healthcare workers featured on the posters range from doctors to

administrative and housekeeping personnel.

"As one of the judges of the panel, I was impressed with the number of

patient safety improvements individuals and groups are making

throughout Pennsylvania and I appreciate the time taken by healthcare

personnel who submitted entries for the contest to tell us about

them," Doering added.

The judging panel for the poster contest was comprised of Patient

Safety Authority board members and management staff. Submissions were

judged according to the following criteria: had a discernable impact

on patient safety to one or many patients, demonstrated a personal

commitment to patient safety, and demonstrated that a strong patient

safety culture is present in the facility. Bonus points were awarded

for those who demonstrated initiative taken by an individual. Winners

received their photo and patient safety efforts highlighted on posters

which can be displayed within their facilities. They also received a

certificate and "I am Patient Safety" recognition pin from the


"Every day, healthcare facility personnel work to improve patient

safety and help keep patients safe from harm when using the healthcare

system. These posters help us to congratulate some of them on a job

well done," Doering said.

The individuals and groups recognized for the "I am Patient Safety"

poster contest and their achievements are as follows (in alphabetical


Sharon Best, Housekeeper 1, Environmental Services (former employee)

Children's Hospital of Pittsburgh of UPMC

Sharon "knew something was not right" with a patient while she was

cleaning his room. Sharon's awareness and immediate action to get help

for the patient, who was having a seizure, showed her commitment to

patient safety.

Terri Bugnizet, RN, BSN, CEN, CPEN, Emergency Department Chester

County Hospital-Penn Medicine

While Terri was reviewing a medication order for a diabetic patient in

the emergency room, she noticed that a physician had incorrectly

ordered a one-time dose and type of insulin that could have resulted

in a serious medication event and injury to the patient. Thanks to

Terri's attention to detail, the patient received the correct type and

dose of insulin.

Kelly Crist, Transcriptionist Unit Clerk, Imaging Services WellSpan

Gettysburg Hospital

[Submitted with Kimberly Wolfe] Kelly pointed out to the appropriate

staff the correct test results for her patient. Kelly ensured timely

and accurate communication of critical test results, which allowed for

immediate and necessary treatment of her patient.

Kathleen Fowler, MSN, RN, CMSRN, Quality Improvement Project Manager

UPMC St. Margaret of Pittsburgh

Kathleen's commitment to patient safety led to implementation of

several process improvements to decrease falls with injury. Kathleen

facilitated the implementation of the Safe Patient Handling Campaign,

which led to a reduction in the number of injuries experienced by

staff when handling or moving patients during care activities.

Kathleen also modified the just culture initiative for UPMC St.

Margaret to encourage staff to learn from events occurring in the


Tim McFeely, RN, BSN, NE-BC, Nurse Manager of the Coronary Care Unit

WellSpan York Hospital

As nurse manager of the Coronary Care Unit and chair of the

resuscitation review team at WellSpan York Hospital, Tim ensures his

team looks at every resuscitation event in the hospital. He works with

his team to dig deep and find every reason why American Heart

Association guideline targets are not met. Tim regularly shares best

practices with his nursing staff, along with outcomes. Through Tim's

leadership, post-cardiac-arrest survival-to-discharge improved from

17.2% in 2011 to 31.6% in 2012.

Ann Norwich, CRNP WellSpan Gettysburg Hospitalist Service WellSpan

Gettysburg Hospital

Ann assumed care of a patient admitted with an altered mental status

whose cognitive condition did not improve after treatment for an

underlying infection. After hours of research, Ann discovered a

significant medication error that occurred on admission and

contributed to the patient's altered mental state. The medication

error was corrected and reported immediately. During investigation of

this event, a previously unknown problem with the electronic

medication reconciliation and ordering process was revealed. Without

Ann's persistence in trying to understand this patient's situation,

this latent error might have gone undiscovered.

Regional Gastroenterology Associates of Lancaster (RGAL) Patient

Safety Committee Team Leaders Jennifer Bean, BSN, RN, Clinical

Coordinator and Infection Control; Trudy Chernich, Patient Safety

Committee Community Representative; Judy Fry, Health Information Team

Leader; Valerie Geyer, MSN, RN, NE-BC, Director of Clinical Services;

Denise Jackson, Billing Associate; Linda Leayman, Manager, Patient

Relations; Elsie Lunger, LPN, Open Access; Cindy Nichols, Surveillance

Coordinator; Connie Ream, Clinical Administrative Assistant; Joan

Schaum, RN, Patient Safety Officer; and Christopher Shih, MD

The patient safety committee at the Regional Gastroenterology

Associates of Lancaster (RGAL) is comprised of individuals

representing various departments from management, endoscopy and office

nursing, infection control and community representation. The RGAL

patient safety team worked together and reviewed its patient

identification process from the time of registration to discharge

through a failure mode and effects analysis, resulting in proper

patient identification and consistent labeling of all pathology

specimens. Zero errors have been made with specimen mislabeling since

this process was implemented.

In 2013, RGAL looked at potential complications for patients with

implanted pacemakers and completed several performance improvement

projects, including one that resulted in quicker insurance approval

turnaround times for patients, which helped reduce the wait times of

patients in need of infusions and reduce their out-of-pocket costs.

Larger process improvements completed in 2013 included a revision of

endoscopy medication management, including drug labeling and coding

for look-alike, sound-alike medications. The RGAL staff also made

suggestions for improved patient safety that included infection

control stations in waiting areas for patients and new chairs for

bariatric patient needs.

Maria Stesko, RN, Operating Room Phoenixville Hospital

While checking medical device items in carts for packaging defects and

expiration dates, Maria found several items missing expiration dates.

After investigating other reprocessed items in storage, Maria noticed

there were others that did not have expiration dates. A call to the

company that supplied the items verified they should have had

expiration dates on them as well. All reprocessed items were pulled

from the shelves and checked. Also, the company requested the

opportunity to do a site visit and review all reprocessed items in the

hospital and surgical center for any other items that were missing the

expiration information to ensure safety.

Roslyn (Roz) Syrkett, Unit Assistant Substance Detox/Behavioral Health

Eagleville Hospital

Roz overheard a patient having a distressing phone call with his

mother. Once the patient went back into his room, Roz followed him to

make sure he was okay. When Roz arrived in the room, the patient was

trying to harm himself. Roz calmed the patient down and ensured he did

not harm himself.

Kimberly Wolfe, Transcriptionist Clerk, Imaging Services WellSpan

Gettysburg Hospital

[Submitted with Kelly Crist] Kimberly alerted the appropriate staff to

the correct test results for her patient. Kimberly ensured timely and

accurate critical test results were given to staff which allowed for

immediate and necessary treatment of her patient.

Rachel Wamba Yadrnak, RN, Pediatric Hematology/Oncology Penn State

Hershey Children's Hospital

As one of the founding members of the Chemotherapy Safety Task Force,

Rachel led staff within the department and brought a "closed

chemotherapy system" into Penn State Hershey Children's Hospital.

Through her work, this transition into chemotherapy administration

systems has decreased the nurses' exposure and risk of chemotherapy

related spills for over three months. Rachel has also worked for two

years to develop and implement an annual chemotherapy competency test

to monitor the skills of the nurses on the unit. This competency test

helps ensure patient safety by promoting consistency and safety in

administration, and continued education on different administration


The Authority will hold the "I am Patient Safety" poster contest each

year from May to October. Winners will be announced during Patient

Safety Awareness Week. To view the posters from this year's "I am

Patient Safety" contest, go to

Patient Safety Awareness Week is a national observance sponsored by

the National Patient Safety Foundation (NPSF) as an education and

awareness-building campaign for improving patient safety at the local

level. This year's theme is "Navigate Your Health.Safely." A patient's

health journey often starts with diagnosis, but experts estimate that

up to one in every 10 diagnoses is wrong, delayed, or missed

completely and that collectively, diagnostic errors may account for

40,000-80,000 deaths per year in the United States.

In September 2010, the Authority published a Patient Safety Advisory

article, "Diagnostic Error in Acute Care" which showed errors related

to missed or delayed diagnosis are frequently a cause of patient

injury and therefore an underlying cause of patient safety related

events. The Authority gives healthcare facilities strategies to

decrease diagnostic errors, along with an educational toolkit that

contains: a research poster about "Pennsylvania Diagnostic Error in

Acute Care," a diagnostic errors measurement worksheet, a patient

education worksheet regarding diagnostic error, a physician checklist

for diagnosis, and a DEER taxonomy chart audit tool. Consumer tips

titled "Help Your Doctor Diagnose You Correctly" are also available on

the Authority's website at

NPSF has linked to the Authority's educational tools on diagnostic

error and has teamed up with the Society to Improve Diagnosis in

Medicine (SIDM) to develop education materials for clinicians, health

systems, and patients and consumers specifically related to better

understanding and prevention of diagnostic errors. For more

information on Patient Safety Awareness Week, go to

SOURCE Pennsylvania Patient Safety Authority

-0- 03/03/2014

/CONTACT: Laurene M. Baker, Patient Safety Authority, (717) 346-1092

CO: Pennsylvania Patient Safety Authority

ST: Pennsylvania



-- DC74460 --

0000 03/03/2014 13:00:00 EDT

Copyright © The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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