Pennsylvania Hospital’s (PAH) Quality and Safety Shared Governance Council presented the 6th annual Josie King Hero Award to a group of staff making a difference in patient safety. Established by the Josie King Foundation – a national organization focused on preventing medical errors and improving care – the award recognizes clinical staff who have demonstrated a commitment to maintaining a culture of safety in their workplace.
This year, the award was presented to a group of employees from the Emergency Department, Behavioral Health, Social Work, and Medical-Surgical, among other departments. Through a collaborative effort, the group developed a brochure centered around care for any patient at risk (PAR) for suicide, self-harm, or harm to others, or for opioid or substance use disorders or elopement (leaving a hospital unsupervised and undetected).
“We conducted a number of root cause analyses and found that the one major factor contributing to patient elopement at hospitals was a gap in communication at the time of handoff of care from one caregiver to another,” said Deborah Drayton, EdD, MSN, RN, NE-BC, clinical director of Medical-Surgical & Oncology, and a member of the PAR workgroup. “We wanted to create a document that would contain all necessary information and protocols for caring for a PAR as staff transition from day to night shifts.”
Displayed on each unit’s safety review board, the brochures can be retrieved by any staff in need of PAR guidance. The brochure provides a checklist of the protocols in caring for a PAR, in addition to best practices for creating a safe environment in a patient room.
To introduce this guide to staff, the workgroup created a virtual escape room. Through accessing a Web link, nursing staff could virtually enter a PAH patient room with the mission to identify ligature risks – anything with a cord, rope, or other material that posed a risk of strangulation – existing in the room. Once all risks were identified, the employee could move onto the next level to identify additional risks in another room.
The brochure also offers instruction on using PAR-specific Kardex – an assessment tool containing details about a patient’s care that an employee will give to a colleague following their shift.
“To quickly identify a PAR, we would use a gray Kardex, rather than our typical white handoff tool,” said Drayton. “We also use gray gowns for PAR, color-coordinated with their Kardex, and add an image of a gray ribbon placed next to the patient’s room number on the safety board as an alert to all staff working on the unit.”
The workgroup received the Josie King Hero Award at a ceremony on September 28, where they presented the PAR brochure to in-person attendees and those attending online. They received a plaque to acknowledge their efforts in patient safety, which is displayed on 5 Cathcart.
The team members felt gratified to be recognized for their efforts. “I feel honored to be part of this team of committed individuals who are focused on keeping patients safe,” said Drayton. “I’m humbled to have contributed to these initiatives and implementing them in our units.”
AWARD WINNERS
- Sara Cohen, MSN, RN, RNC-NIC, NPD-BC, WTA Clinical Nurse Education Specialist
- Deborah Drayton, EdD, MSN, RN, NE-BC Clinical Director of Medical-Surgical & Oncology
- Lauren Ellis, MSN, RN, CEN, NE-BC Nurse Manager of Emergency Department
- Victoria Fisher, RN Behavioral Health Nurse
- Stephanie Hollister, MSN, RN Behavioral Health Nurse Manager
- Patty Inacker, DSW, MBA, LCSW Behavioral Health Service Line Administrator
- Maria Joyce, MSN, RN Resource Manager for Nursing Network Center
- Humza Khalid, MD, Medicine Resident
- Philip Landis, DNP, RN, CEN, NPD-BC Clinical Nurse Education Specialist
- Patricia Maguire, MSN, RN, CMSRN, CNL 5 Cathcart Nurse
- Lisa McNamee, MSN, RN, PMHCNS-BC Clinical Nurse 4, Behavioral Health
- Emily Murphy, BSN, RN 5 Cathcart Staff Nurse
- Cynthia Onorevole, LSW Licensed Clinical Social Worker, Clinical Resource Management
- Angela Ross, MSN, RN, OC, 5 Cathcart Nurse Manager
- Joanne Ruggiero, MSN, RN, MA, NE-BC, CMSRN Former Clinical Director for Women’s & Behavioral Health Services
- Florrie Vanek, MSN, RN, NE-BC Director, Nursing Education, Practice, and Magnet Program
- Frank Visco, BSN, RN, RN-BC 6 Cathcart Nurse