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Medication Reconciliation Process Failures: a Study of Serious Events Reported by Pennsylvania Hospitals 48 Incorrect Patient Heights Amy Harper Et Al

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Medication Reconciliation Process Failures: a Study of Serious Events Reported by Pennsylvania Hospitals 48 Incorrect Patient Heights Amy Harper Et Al Former insurance executive Wendell Potter PATIENT on the brokenness of U.S. healthcare Generally considered safe, minimally SAFETY invasive surgery still carries risks March 2021 | Vol. 3, No.1 A deep dive into outpatient medication safety I think vaccines are: Lifesaving Unsafe I’m not sure Can we talk? LETTER From the Editor Patient safety is one of those passions. It ment of outpatient electronic health re- is a common aspiration, a common vision cords to mitigate these risks. that brings healthcare workers, health- care systems, and patients together. As Wendell Potter, well-known former-health- the year turns to spring, we look forward insurance-executive-turned-whistleblower, with renewed spirit to the challenges that shares his perspectives on the healthcare still lie ahead. With this March issue of Pa- insurance industry in the United States, tient Safety, we acknowledge Patient Safe- how the average person can sniff out ty Awareness Week with our colleagues propaganda, and how patients can take across the country, bringing you stories charge of their own care. You do not want and research to both inform and inspire. to miss this interview. From our cover: Patient Safety’s managing Other features include original articles re- editor, Caitlyn Allen, sits down for some lated to medication reconciliation, medi- vaccine straight talk with JoAnn Adkins, cation errors related to patient height, infection preventionist; Dr. Lily Brown, and injuries from misplaced nasogastric psychologist; and Susan Senator, the tubes, and perspective pieces from both mother of an autistic child who provides a patients and providers related to patient glimpse into the vaccine-hesitant culture height, resilience, derogatory language and what made her change her mind. The in medical records, and the importance discovery of vaccines is one of the great- of being your own advocate. est contributions to mankind in the histo- ry of medicine. Being able to bridge the I hope that your passion for safer care gap between fact and fiction takes real and a brighter tomorrow continues to conversations, a real understanding of burn through these difficult times. If you have stories to share about your experi- Regina Hoffman, the fears and skepticism of patients and families, and mutual respect. ence as a clinician or as a patient through Editor-in-Chief this pandemic, please do not hesitate to Patient Safety Also, from our cover: While minimally submit a perspective piece to our edito- invasive surgery (like the laparoscopic rial team. Original research, quality im- provement initiatives, and case studies he world as we knew it is only removal of a gall bladder) is generally are also welcome at any time. a distant memory. It has been a safe, it is not without risk. Patient Safe- year since everything changed. ty Analyst Lea Anne Gardner shares her This journal was designed for our authors Kids came home from school— findings in an original analysis of Penn- to freely share the important work they some are still home. Meetings moved sylvania Patient Safety Reporting System T do to improve patient safety, and for our from downtown conference rooms to data. She includes the types of surgeries readers to freely receive the information, overcrowded dining rooms. Toilet paper and related injuries, patient outcomes, strategies, and lessons learned to make almost became a black-market commod- and measures to minimize this some- the care they provide and receive safer. ity. Our healthcare workers and health- times-underappreciated risk. care systems were pushed beyond their Authors Dr. Karen Zimmer, Dr. David Stay safe and stay well! limits. A half million people died in the Classen, and Jessica Cole walk us through United States alone and millions more their approach to creating a new catego- recovered. Some initiatives were put on rization schema for medication errors hold and others fast-tracked through in the ambulatory setting. This work not what in “normal” times would take years. only helped them to better understand One thing is for certain, none of us are medication safety errors in this setting, the same. And although we are not the but also, perhaps even more importantly, same, there are passions that we contin- will inform future work in the improve- ue to share. 2 I PatientSafetyJ.com I Vol. 3 No. 1 I March 2021 ABOUT PATIENT SAFETY Mark Jarrett, MD, MBA, MS, Northwell Health Matthew Keris, Esq., Marshall, Dennehey, Warner, Coleman & Goggin As the journal of the Patient Safety Authority, committed to the vision of Stephen Lawless, MD, Nemours Children’s Health System “safe healthcare for all patients,” Patient Safety (ISSN 2689-0143) is fully Michael Leonard, MD, Safe & Reliable Healthcare, LLC open access and highlights original research, advanced analytics, and hot James McClurken, MD, Doylestown Health, Lewis Katz School of Medicine at topics in healthcare. Temple University Patrick J. McDonnell, PharmD, Temple University School of Pharmacy The mission of this publication is to inform and advise clinicians, adminis- Dwight McKay, BSL, Lancaster Rehabilitation Hospital trators, and patients on preventing harm and improving safety, by providing Ferdinando L. Mirarchi, DO, UPMC Hamot evidence-based, original research; editorials addressing current and some- Dona Molyneaux, PhD, RN, Frances M. Maquire School of Nursing and Health times controversial topics; and analyses from one of the world’s largest Professions, Jefferson Health; Gwynedd Mercy University adverse event reporting databases. Gina H. Moore, BSN, RN, Christiana Care Health Services Rustin B. Morse, MD, Nationwide Children’s Hospital We invite you to submit manuscripts that align with our mission. We’re Adam Novak, MA, Michigan Health & Hospital Association particularly looking for well-written original research articles, reviews, Barbara Pelletreau, MPH, RN, Dignity Health commentaries, case studies, data analyses, quality improvement studies, Julia C. Prentice, MSPH, PhD, Betsy Lehman Center for Patient Safety or other manuscripts that will advance patient safety. Mitesh Rao, MD, MHS, Stanford School of Medicine Cheryl Richardson, MPH, RN, Penn State Milton S. Hershey Med. Center All articles are published under the Creative Commons Attribution – Lisa Rodebaugh, BS, Mercy Ministries Noncommercial license, unless otherwise noted. The current issue is Jeffrey Stone, PhD, Penn State University available at patientsafetyj.com. Jennifer Taylor, PhD, Drexel University The patient is central to everything we do. Patient Safety complies with Carlos Urrea, MD, Hillrom the Patients Included™ journal charter, which requires at least two patient Linda Waddell, MSN, RN, Wolff Center at UPMC members on the editorial board; regular publication of editorials, reviews, Eric Weitz, Esq., The Weitz Firm, LLC or research articles authored by patients; and peer review by patients. Margaret Wojnar, MD, MEd, Penn State College of Medicine Zane R. Wolf, PhD, RN, LaSalle University This publication is disseminated quarterly by email at no cost to the sub- scriber. To subscribe, go to patientsafetyj.com. ACKNOWLEDGMENTS A special thanks to our reviewers: PRODUCTION STAFF Scott W. Cowan, MD, Jefferson Health Regina M. Hoffman, MBA, RN, Editor-in-Chief Dan Degnan, PharmD, MS, Purdue University College of Pharmacy Caitlyn Allen, MPH, Managing Editor Michael Gaunt, PharmD, ISMP Eugene Myers, BA, Associate Editor Kelly Gleason, PhD, RN, John Hopkins School of Nursing Jackie Peck, BS, Layout Editor Jennifer Hamm, BS Shawn Kepner, MS, Data Editor Rebecca Jones, MBA, RN, Patient Safety Authority Krista Soverino, BA, Graphics Kathleen Law, DNP, MS, RN, Riley Hospital for Children Javier F. Magrina, MD, Mayo Clinic Brittany H. WMcCann, PharmD, MEd, Pennsylvania Hospital EDITORIAL BOARD Dwight McKay Julia Prentice, PhD, Betsy Lehman Center for Patient Safety Joshua Atkins, MD, PhD, Hospital of the University of Pennsylvania Cheryl Richardson, MPH, RN, Penn State Health Milton S. Hershey Med Center Russell Baxley, MHA, Beaufort Memorial Hospital Lindsey Valentine, MD, Cleveland Clinic OBGYN & Women's Health Institute Mark E. Bruley, BS, ECRI Institute (retired) Michael A. Bruno, MD, Penn State Milton S. Hershey Medical Center Michael R. Cohen, MS, RPh, Institute for Safe Medication Practices Patient Safety Authority Daniel D. Degnan, PharmD, Purdue University School of Pharmacy 333 Market Street - Lobby Level Barbara Fain, JD, MPP, Betsy Lehman Center for Patient Safety Harrisburg, PA 17101 Kelly Gleason, PhD, RN, Johns Hopkins School of Nursing patientsafetyj.com Hitinder Gurm, MD, Michigan Medicine [email protected] Julia A. Haller, MD, Wills Eye Hospital 717.346.0469 Jennifer Hamm, BS, Fred Hamm, Inc. Ann Hendrich, PhD, RN, Building Age-Friendly Health Systems, John A. Hartford Foundation; formerly Ascension Healthcare Together we save lives Patient Safety I Vol. 3 No. 1 I March 2021 I 3 Contents March 2021 I Vol. 3, No.1 2 LETTER FROM THE EDITOR 6 ENGAGING PATIENTS PERSPECTIVES 6 WE ALL WIN WHEN PATIENTS SPEAK UP LISA RODEBAUGH ET AL. A conversation with patient advocate Lisa Rodebaugh; executive director of the Patient Safety Authority (PSA), Regina Hoffman; and PSA director of Engagement, Caitlyn Allen. 34 OUR BEST SHOT: BRIDGING THE GAP IN THE VACCINE DIVIDE CAITLYN ALLEN Infection preventionist JoAnn Adkins; psychologist Dr. Lily Brown; and mother of a son with autism, Susan Senator share their insights into how vaccines work, how to recognize when anxiety may be clouding our judgment, and how both sides
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