Volume 10
Issue 13
June 26, 2015
PRESBYbulletin Penn Presbyterian Medical Center
Congrats to the PPMC VAD Program! At the Intermacs annual meeting last month, Penn Presbyterian Medical Center received the Vanguard Center Award for excellence in data quality and compliance. Intermacs – which stands for Interagency Registry for Mechanically Assisted Circulatory Support – is the United States national registry for patients who are receiving durable mechanical circulatory support device therapy to treat advanced heart failure. This registry was devised as a joint effort of the National Heart, Lung and Blood Institute (NHLBI), the Centers for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), clinicians, scientists and industry representatives. In order to receive the award, PPMC had to have more than 95 percent data compliance with the International Intermacs Database, and 100 percent regulatory compliance for the data over a one-year time period, with at least 20 participants enrolled. Congratulations to our VAD program faculty and staff!
National Hospital Week
Jim Ballingfoff, CNO (center), with award winners Emmaline Carrasco (left), and Sharon Nicholas. Not pictured: award winners Kim Onate and Jeffrey Atzert.
UPHS NURSING CLINICAL EXCELLENCE AWARDS Each year, the UPHS Nursing Clinical Excellence Awards recognize nurses for their exceptional commitment to high quality patient care as well as their clinical knowledge and professional achievements. Congratulations to PPMC’s winners of these four prestigious awards. For a full list of winners, please see the Presby Bulletin online. Sharon Nicholas, BSN, RN - Lillian Brunner Award for nurses demonstrating the highest quality of patient care and exhibit excellence in clinical judgment. Kim Onate, BSN, CGRN - Rosalyn J Watts Award for nurses who establish therapeutic relationships with patients and their families. Jeffrey Atzert, BSN, RN - Dorothy Botdorf Award for nurses with leadership competencies. Maria Emmaline Carrasco, BSN, MA, RN, CCRN-CMC - Helen McClelland Award for nurses who utilize research and/or evidence in delivery of patient care.
PPMC Thanks…
Hannah Carson, CIC, Infection Preventionist, who joined other PPMC faculty and staff in volunteering her time to teach local kids about healthy habits. In the third meeting of an eight-week series focused on promoting healthy lifestyles and community connectivity, Hannah worked with local children to teach them about the importance of hand hygiene. Using a special hand gel and a black light, Carson used hands-on activities to demonstrate handwashing techniques aimed at reducing the risk of spreading germs. Last month, Laura Solano, MSN, RN, CCNS, CCRN, also met with local children to lead a session on handsonly CPR. The lessons, which Laura has also taught as part of the annual Philadelphia Science Festival, focused on how to tell if someone needs CPR, and proper technique. Kids practiced proper CPR techniques for infants as well as children and adults.
Thank you to all our volunteers! If you are interested in participating in a community service event, please visit: www.pennmedicine.org/community.
JAZZ FEST 2015 We are excited to announce that this year’s Jazz & Arts Festival will be on July 18th, from 12-7pm in Penn Presbyterian Medical Center Saunders Park. The headliner this year will be Sonny Fortune, the internationally-renowned jazz saxophonist. Mr. Fortune was a disciple of John Coltrane, and has played with Miles Davis, Dizzy Gillespie, and Buddy Rich, to name a few. Fortune’s reputation, as quoted by Stereophile magazine, is “one of the most intriguing alto players in contemporary jazz.” The Lancaster Avenue Jazz & Arts Festival is a great opportunity for families and jazz lovers of all ages to experience a day of free jazz and more, including a food truck pavilion, vendors, photo booth, facepainting, family friendly activities, computer pop-up lab, community resources, and on-site activities.
Human Error: Console Don’t Discipline When we investigate Safety Net reports, we usually find one of three behaviors: (1) Human Error; (2) At-Risk Behavior; or (3) Intentionally Reckless Behavior. In our weekly Just Culture quiz, 40 percent of those who responded to the recent example of a Human Error thought it was At-Risk or Intentionally Reckless Behavior. This means that 40 percent of us might have blamed or punished a colleague for a mistake. Sometimes it is hard to see the difference between a mistake and something risky or reckless. Human Errors are mistakes, slips, lapses… things we didn’t do on purpose. For example: ... you accidentally order methimazole instead of metronidazole. ... you put supplies away while a colleague is telling you a funny story, and you put the Foley catheters in the wrong supply bin. ... you mistakenly put Patient A’s progress note into Patient B’s chart after a long and tiring shift. A Just Culture does not punish people for making mistakes like these, no matter what the outcome. We know we are human; we are prone to certain kinds of errors such as substituting one thing for another or missing a step while being distracted. Healthcare in general still has a fairly punitive culture where people are blamed for a human error – sometimes even at PPMC. So how do you recognize a mistake? If the person did not intend to cause harm or if their behavior was not intentionally risky, then it’s a mistake. It’s a human error. As long as the person did not deliberately disregard the risk, and was acting in good faith within their scope of practice, then the right response is to console our colleague. It does not mean we ignore the mistake – instead, we redesign our systems to protect us from being human.
For more information, please visit www.lancasteravejazzfest.com Contact Us: Katie Delach | katie.delach@uphs.upenn.edu | http://news.pennmedicine.org/inside/presbybulletin/