Volume 10
Issue 14
July 10, 2015
PRESBYbulletin Penn Presbyterian Medical Center
David Kozart, MD, Medical Staff Award
What is a “Just Culture”? You’ve probably been seeing and hearing a lot about PPMC’s Just Culture initiative. But, do you know what it means to be a “Just Culture”? Just Culture: A non-punitive approach to error reporting is based on the concept that people make errors all the time - not because they’re incompetent or uncaring or careless, but rather because of the complicated systems in which they work. In such an approach organizations, organizational leaders and individuals/colleagues do not seek to punish people who report mistakes or who make mistakes. Rather they look upon mistakes as opportunities for system improvement, and create an environment where people feel comfortable and responsible for reporting and discussing these errors. Under such “Just Culture” conditions, individuals are not blamed for ‘honest errors’, but are held accountable by their manager for repetitive at-risk behavior, and for reckless behavior.
At the Semiannual Medical Staff meeting on June 10, the Annual David M. Kozart, MD, Medical Staff Award was presented. The David Kozart, MD, Medical Staff Award is intended to recognize a medical staff member who has demonstrated excellence in patient care and medical staff leadership. This year’s awardee, John Flamma, MD, represents these ideals in wonderful fashion. Dr. Flamma joined the active medical staff in 1991, immediately after finishing his residency in emergency medicine at Presby. Since that time he’s served on many of the same committees as Dr. Kozart, culminating in his term as president of the medical staff in 2007 and currently serving as Chief of Emergency Medicine at PPMC and Vice-Chair of the Department of Emergency Medicine at Penn. Dr. Kozart is remembered as a prominent ophthalmologist, beloved mentor, teacher, administrator and medical staff leader revered by colleagues and peers. His outstanding contributions spanned over four decades at PPMC.
YOUR ACTIONS PREVENT REACTIONS; KNOWING ALLERGIES SAVES LIVES Did you know that according to the Joint Commission Center for Transforming Healthcare, “an estimated 80 percent of serious medical errors involve miscommunication when patients are transferred or handed-off ”? For this is reason, the Nursing Quality Council is continuing to focus on improving RN to RN handoff. Last year, the council identified five key components crucial for all handoffs. The five components are: introduction of self, patient’s name, date of birth, allergies, and if the nurse asked if the patient had any questions. Last year, the council focused on improving compliance with date of birth. This year, they worked to improve communication around patient allergies.
PPMC Thanks… Leon Hinman and Stephen Davis, PPMC Chefs from Sodexo, who were the last volunteers in the semi-annual uGo series, an eight-week program run twice each year by the People’s Emergency Center that features activities that promote healthy lifestyles and community connectivity. Hinman and Davis held hands-on sessions to teach kinds about making healthy food choices and how to cook healthy meals.
From April 2014 to March 2015, over 700 patients presented to the Presby ED with an allergic reaction, angioedema, or rash. Furthermore, adverse drug reactions are the fourth to sixth leading cause of death in the United States. Drug reactions may result in diminished quality of life, increased physician visits, increased health care costs, hospitalization, and even death. In early June, the Nursing Quality Committee hosted events in common areas with coffee, fresh fruit, and granola bars to remind nurses to communicate Name, Birthdate, and Allergies with every patient handoff, every time.
Thank you to all our volunteers who participated in the uGo community outreach series! The next series will take place in the fall. If you are interested in participating in uGo, or another community service event, please visit: www.pennmedicine.org/community Contact Us: Katie Delach | katie.delach@uphs.upenn.edu | http://news.pennmedicine.org/inside/presbybulletin/