Pennsylvania Healthcare Workers Recognized by the Patient Safety Authority

Twenty-one Pennsylvania healthcare workers from 12 facilities are being recognized by the Pennsylvania Patient Safety Authority for their efforts to improve patient safety within their healthcare facilities. The healthcare facilities received posters depicting the healthcare workers and their efforts for display during National Patient Safety Awareness Week, March 13-19, 2016.
  
"This event is always a lot of fun because it gives the Authority the chance to see all of the good work done, not just by the recognized winners, but by so many individuals and groups who go to work in a healthcare facility every day," says Mike Doering, executive director of the Pennsylvania Patient Safety Authority. "Again, this year we've recognized those who work in all areas of the institution because the Authority believes everyone must work together for patients to have the best possible outcome when using the healthcare system."
  
The recognized healthcare workers recently attended the Authority's public board meeting and luncheon where they met with board members and received "I Am Patient Safety" pins and certificates for their achievement. Winners will also be featured in the forthcoming March Pennsylvania Patient Safety Advisory and the 2015 Annual Report, the latter with their photos on the cover.
  
The judging panel for the poster contest was comprised of Patient Safety Authority board members and management staff. The panel judged de-identified submissions according to the following criteria: had a discernible 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.
  
"Recognizing healthcare workers for the good work that they do is always a highlight for the Authority," Doering says. "While judging gets tougher every year, I encourage all healthcare staff within ambulatory surgery facilities and hospitals to continue to nominate those individuals and groups you think are committed to patient safety within their institutions.
  
"Good work is being done, we know. Let's hear more about the efforts made by Pennsylvania's healthcare workers who make every day patient safety day," Doering adds. 
  
The Authority received 171 nominations from Pennsylvania healthcare facilities in 2015. The "I Am Patient Safety" poster contest is held each year from May to October. Winners are announced during Patient Safety Awareness Week. To view the posters from this year's "I Am Patient Safety" contest, go to www.patientsafetyauthority.org and click on brochures.
  
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 message is "every day is patient safety day." 
  
The individuals and groups recognized for the "I Am Patient Safety" poster contest and their achievements are as follows (facilities in alphabetical order*):
*Any included numbers and/or results were provided for publication by the recognized healthcare facilities. The Authority has not confirmed, and bears no responsibility for these numbers and/or results.
  
Tania Hoyer, RN, BSN, CCRN-CSC
Clinical Educator, Intensive Care Unit (ICU), Cardiovascular Intensive Care Unit (CVICU), Interventional Cardiology Unit (IVU), and Post Anesthesia Care Unit (PACU)
Doylestown Hospital

As a clinical educator, Hoyer coordinated a comprehensive unit safety program to implement decreased sedation and early mobility protocols. Working with ICU nurses, respiratory therapists, and physical therapists, Hoyer helped ICU patients be more alert and more mobile without more restraints and without more adverse events (e.g., falls). Hoyer's efforts also helped the nursing culture shift from one in which all ICU patients were "too sick" to get out of bed to a culture of mobilizing all patients, as appropriate based on their medical condition. In the nonsurgical patient population, the average time on a ventilator decreased from 4.2 days to 3.5 days. In November 2013, the baseline ICU length of stay (LOS) in this same population averaged 5.6 days; in January 2015, the average LOS decreased to 3.8 days.
  
Brenda Prabhakar,
RN Emergency Department
Doylestown Hospital
  
As a nurse in the emergency department (ED), Prabhakar focused on reviewing each case to allow early detection of the septic (infection) state, proper collection of blood cultures, aggressive administration of intravenous fluids, routine ordering of lactate-level tests, and administration of clinically appropriate antibiotics. With her findings, Brenda educates clinical staff with best practices to improve patient outcomes and plans to expand education to include staffers in Emergency Medical Services.
  
Mashiul Chowdhury, MD
Chief of Infectious Diseases, Director of Infection Control and Antibiotic Stewardship Program
Cancer Treatment Centers of America® (CTCA) at Eastern Regional Medical Center
  
As chief of infectious diseases, Chowdhury developed and launched guidelines for surgical antibiotic prophylaxis, post-splenectomy vaccination, appropriate pneumococcal vaccination, and antibiotic prophylaxis and vaccination for patients undergoing stem cell transplants. He also improved the turnaround time for receiving all culture results and led a multidisciplinary Ebola task force. Chowdhury is described by a colleague as "singularly focused on achieving the best possible outcome for the patient. He has succeeded in bringing the principles of clinical medicine, antibiotic stewardship, and infection prevention together to meet this objective."
  
Anne Gennaria, RN, BSN
Diagnostic Testing Nurse
Suzanne Popowicz, BSN
Einstein Medical Center Montgomery  
  
Gennaria and Popowicz recognize the importance of positive patient identification and always take the time to follow the appropriate process for identifying patients in the surgical/procedural areas. Their commitment and diligence in adhering to this important procedure prevents wrong-site surgeries.
  
Tony Wise
Environmental Services
Einstein Medical Center Montgomery

As a member of the environmental services team, Wise stands out as someone willing to step outside his comfort zone to keep patients safe. Wise was buffing hospital floors with his "Zamboni-like" machine. As he was passing one of the rooms, a bed alarm began to ring and he noticed an elderly patient trying to get up. Wise immediately stopped his machine and went to talk to the patient. He asked the patient to stay in bed until the nurse responded soon after. All agreed Wise's quick thinking and engagement of the patient in a conversation helped to keep the patient safe from a fall. When he was later thanked for his quick action, Wise said, "That is what we do. We are here to help our patients and keep them safe."
  
Dorothy Borton, RN, BSN, CIC
Infection Prevention Manager
Einstein Medical Center Philadelphia
Einstein Medical Center Elkins
Park MossRehab and Willowcrest
  
As infection prevention manager, Borton focused on decreasing surgical site infections (SSIs) associated with hip and knee arthroplasty. When an increase in SSIs was identified, Borton developed interventions within the facility that included establishing a multidisciplinary team from all areas across the continuum of care. She led the team to develop an electronic SSI database that was used as an audit tool to monitor process measures of surgical-site bundle. Borton worked closely with the SSI team and joined the Surgical Unit Safety Initiative collaborative to address cultural and teamwork issues. The interventions resulted in fewer SSIs associated with hip and knee arthroplasty, from 2.85% (CY 2013) to 1.12% (CY 2014).
  
Tammie Moritz, PA-C
Surgical Physician Assistant
Forbes Hospital Allegheny Health Network
  
A patient was scheduled to have surgery on the left side of her neck to prevent a stroke. Upon chart review and discussion with the patient, who was slightly confused, there was a question as to which side of the neck was to be operated on. As a surgical physician assistant, Moritz initiated a "hard stop" at this point and pulled the patient's records so the surgeon could review them. It was discovered that the patient should have surgery on the right side of her neck to prevent a stroke, not the left.
  
Bonnie Morris, RN, MSN
Oncology Manager
Guthrie Robert Packer Hospital 
  
Morris understands how important hand hygiene is to prevent healthcare-associated infections (HAIs), especially when caring for cancer patients. When an automated hand hygiene monitoring system showed below-average compliance levels within the unit, Morris encouraged the staff to do better. She posted monthly results of staff progress in meeting their goals of better hand hygiene. Using Halloween and football themes to encourage progress, Morris and the staff celebrated success at every turn. Today the unit boasts a consistent compliance rate of more than twice the national average. The unit had zero central line-associated bloodstream infections (CLABSIs) and zero catheter-associated urinary tract infections (CAUTIs) in 2015.
  
George Miller, RPh
Clinical Pharmacy Manager
Jeanes Hospital
  
As a clinical pharmacy manager, Miller worked closely with physician leadership, nursing staff, and the hospital pharmacy and therapeutics committee to develop protocols to improve the efficiency of anticoagulant therapy and other medications. Because of Miller's efforts, the protocols have resulted in an 80% reduction of adverse events related to warfarin. As a member of Jeanes Hospital Patient Safety Committee, Miller actively works with staff to reduce medication safety events by partnering with them, not blaming them. He also encourages staff to engage and is accessible at all times.
  
Adebola Onanuga, RN
Medical Surgery Geriatric
Lehigh Valley Hospital – Cedar Crest
  
A surgeon placed orders for an insulin drip for a patient being prepared for surgery. Onanuga questioned the order because the patient did not have a history of diabetes. After reviewing the patient's lab work, she discovered the patient's glucose level was high. The notes also showed the patient was receiving glucose through IV fluids. Onanuga tested the patient's glucose level. She notified the surgeon of the different readings. It was suspected the bloodwork performed in the morning may have been collected near the IV where the glucose was being infused into the patient, thereby causing a false reading for high glucose. The surgeon ordered another glucose test to confirm Onanuga's findings, and it showed the patient's glucose level was normal, not elevated. The surgeon discontinued the insulin drip.
  
Lee Ann Hollingsworth Patient Care Technician
Preadmission Testing Unit
Pennsylvania Hospital of the University of Pennsylvania
  
As a patient care technician, Hollingsworth works in the preadmission testing unit, where patients receive preoperative testing prior to surgery. While performing a routine electrocardiogram (EKG) on a patient scheduled for surgery, Hollingsworth noticed an abnormal reading indicating a heart attack. The patient was scheduled for surgery unrelated to anything cardiovascular, and he told Hollingsworth he felt fine. Hollingsworth remained calm and tested the patient several more times. All of the EKGs read abnormal as well, and even though the patient said he felt fine and resisted going to the emergency room (ER), Hollingsworth called ahead to the ER and assured the patient he would be taken right away. She even called his wife and together they encouraged him to allow Hollingsworth to call 911. The patient was admitted to the hospital and had heart surgery the next morning. 
  

Rachel Benensky, RN
Med/Surg Telemetry
Phoenixville Hospital
  
As an RN, Benensky received instruction from the off-going RN that the physician for a patient, who had just undergone a complex urological surgical procedure, verbally ordered that the patient be discontinued from his suprapubic tube. Rachel questioned the appropriateness of this order and whether this was in the scope of practice for an RN. Benensky called the physician to verify the order and receive clarification. The physician stated he wanted the patient's urinary bladder catheter removed, not the suprapubic catheter, which would have compromised the patient's recovery. The next day, Benensky also reported her experience of the facility's Safety Huddle so that all staff could learn from the incident.
  
Jodi Cheeks, RN Unit Coordinator
Kimberley DiBlassio, RN
Med/Surg Telemetry
Phoenixville Hospital
  
When a patient was admitted to the facility with uncontrollable hiccups, Cheeks questioned the medication prescribed to the patient because it was not the type of medication she knew to be prescribed for hiccups. When pharmacy staff was not readily available, she contacted her unit coordinator, Jodi, to ask if she had known of the medication being prescribed for hiccups. Jodi did not. The pharmacy staff checked with the physician and confirmed it was the wrong medication for the patient. The patient was given the correct medication. The information concerning the look-alike, sound-alike drug was shared with the facility's Safety Huddle as a "good catch."
  
Madonna Nowak, RN
Operating Room (OR)
Phoenixville Hospital
  
A patient who sustained a broken hip was admitted to the hospital for surgery. During preoperative testing, the patient was found to have a positive blood culture, which was reported directly to the ordering physician. At the same time, the patient was transported to the preoperative holding area and assessed by the surgeon and anesthesiologist. Upon completing patient identification, consent, and other assessments per hospital policy, the patient was moved to the OR suite to be prepared for surgery. Nowak, the circulating nurse that day, reviewed the patient's medical-record data and discovered the positive blood culture results. Recognizing the clinical significance and potential safety issue, she immediately notified the surgeon. He had not been notified of the positive blood culture results. The surgery was postponed until the patient received treatment for the infection.

  
Lauren Bailey, Registered Dietitian
Becky Bryson, Dietary Hostess
Sally Loyd, Dietary Hostess
Julie Spickler, Dietary Hostess
Harrisburg Hospital – Pinnacle Health System
  
As members of the dietary staff, Lauren, Becky, Sally, and Julie have used their simulated falls prevention education to change the culture where they work. Each has taken ownership of falls prevention on the nursing units and fostered positive working relationships with clinical staff. Becky alone has saved at least eight patients from serious harm due to a fall. Whether responding to bed alarms or paying close attention to patients identified as a fall risk, the dietary staff is committed to preventing falls with harm.
  
Janice Reppert
Environmental Services Manager
St. Luke's University Health Network - Anderson Campus
  
As the environmental services manager, Reppert participates on the hospital's patient safety and quality infection control committees. She offered to be a TeamSTEPPS™ trainer and encouraged many team members to become "secret shoppers" in a program she helped develop to reduce Clostridium difficile (C. diff) infection among patients at the facility. Reppert also coordinates the "bleach cycle" cleaning of all clinical units, with team huddles every day to discuss progress towards or barriers to keeping patients safe. She is always ready to lend a helping hand and does bedside environmental services rounds with patients to get feedback on hospital cleanliness. 
  
Source: Pennsylvania Patient Safety Authority