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TO HEALTH, MEDICAL, AND NATIONAL EDITORS:
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
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
[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
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
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
[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 www.patientsafetyauthority.org.
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 www.patientsafetyauthority.org.
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 www.npsf.org.
SOURCE Pennsylvania Patient Safety Authority
/CONTACT: Laurene M. Baker, Patient Safety Authority, (717) 346-1092
CO: Pennsylvania Patient Safety Authority
IN: MTC ENV PHA MEQ
-- DC74460 --
0000 03/03/2014 13:00:00 EDT http://www.prnewswire.com
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