Kyle Upton, Nursing Assistant ~ University of Iowa Hospitals and Clinics
Kyle was responsible for saving the life of the infant patient. He was asked by the nursing care team to evaluate this patient’s monitor to see if there was something mechanically wrong. He quickly recognized that the pulse oximeter monitor’s malfunction was due to inadequate cardiac output from an unexpected ductal dependent lesion (hypoplastic aortic arch and aortic coarctation) presenting unexpectedly on day of life 9 and not from a probe malfunction. By recognizing this and quickly notifying the medical team, the medical team was able to rapidly make the diagnosis and medically stabilize the infant by medically re-opening the duct. His rapid reaction that the problem was medical and not mechanical saved this patient’s life.
Dr. Syed Ahmad ~ National Guard unit ~Florida
Dr. Ahmad, throughout his career, has been focused on patient safety. He has built his career with medical error prevention in mind and has worked hard to commit himself to prevent medical error. Dr. Ahmad throughout his career has always been cognizant of ordering extremity x-rays for the correct side of the body on his patients. This has prevented the needless exposure to harmful radiation to many of his patients.
He recalls his intern year of residency. He had ordered an ankle x-ray on the left foot when the patient had complained of right ankle pain. The error was luckily picked up by the x-ray technicians that were on duty at that time. This left a profound impact on Dr. Ahmad and his career. He has made it his personal goal to ensure that something like this never happens again on his watch. Furthermore, Dr. Ahmad, throughout his career, has also worked tirelessly to prevent medication error. He arduously avoids using confusing acronyms such as QD vs QID. He instead consistently makes it a point to prescribe medications as once daily or four times daily. In order to prevent confusion, he always writes fractional medication doses that are preceded by a zero and a decimal. This has gone a long way to preventing patients from receiving possibly ten times the intended dose of a medication. In addition to avoiding these very important documentation pitfalls, Dr. Ahmad diligently confirms a patient’s identity repeatedly throughout his extremely busy shifts in the emergency department. When he first encounters a patient, when he later re-evaluates a patient and then again at the time of disposition he asks his patients to confirm their identity. Dr. Ahmad has been a dedicated professional committed to preventing medical error in his practice. He truly embodies the physician ethos of do no harm. His patients have, throughout his career, emplaced special trust and confidence in his abilities and his professionalism. His dedication to duty and commitment to his patients reflects great credit upon
himself, his hospital and his medical profession.
Sara Chase, RN ~ LincolnHealth
Sara went to her supervisor concerned about a medication dose she felt was too high. She contacted the pharmacy who instructed her to speak to the physician. The physician ordered the med to be given as prescribed. Still not comfortable, Sara contacted the pharmacy a second time. The pharmacist then contacted the physician and the medication order was changed to the appropriate dose.
Master-Sergeant Robert (“Rob”) Kilgallon
MSG Kilgallon was the only medic in direct support of an Audie Murphy leadership exercise involving hundreds of Army ROTC Cadets and cadre from all over Florida. A group of cadets was gathered and MSG Kilgallon overheard them talking about a cadet who they said they thought had food poisoning and was told to go lie down. After hearing this, MSG Kilgallon asked some standard medical history questions of the cadets. The story did not add up and he then went to check on the mentioned cadet himself. Finding the patient in the fetal position, he quickly surmised that the patient wasn’t sick from food, and then proceeded to do a more thorough history and physical assessment. He immediately realized that the patient was worse than it seemed. MSG Kilgallon placed a reflective safety belt on the patient and rapidly got him to an emergency department due to concern for appendicitis. After evaluation in the emergency department, the patient was taken to surgery for an emergency appendectomy. MSG Kilgallon’s keen insight, accurate evaluation and assessment, rapid action, and commitment to patient safety resulted in this patient being safely transported from the field and subsequently receiving the care needed for a potentially serious condition.
Colonel Dave Butler ~ First Military Recipient of the Josie King Award
Colonel Dave Butler served over four decades in the U.S. Army and Florida National Guard. Starting during the Vietnam War, Dave was part of the Military Advisory Command Vietnam – Studies and Observation Group. Throughout his decades of
Darra Schmidt, BSN, RN, OCN ~ Atlanta Cancer Care, Alpharetta ~ Northside Hospital
Darra has been an RN for 10+ years. She joined Atlanta Cancer Care in 2012, and Northside Hospital in January 2013. Darra has been an OCN Certified RN since 2010 and became a Level IV RN in 2018. Darra began her role at ACC as a “float nurse.” This position required that she travel between several of the ACC offices, and work with many different providers, nurses, and members of the oncology care team. This provided Darra with a unique perspective of treatment provided to our patients. Since settling in the Alpharetta office, Darra has utilized her experience to identify best-practices for nurses. She is known as an expert in oncology nursing. She serves as a preceptor for new nurses, and a role model for existing staff. Darra has exceptional attention to detail and is passionate about patient safety. She volunteered to serve as Patient Safety Champion for ACC Alpharetta and continually seeks ways to improve processes and delivery of care. Darra recently developed a “New Chemo Treatment Chart Checklist.” This tool is used by the clinical team to assure that all necessary tasks, documents, and approvals have been completed prior to the patient’s first visit in the infusion suite. Utilization of the tool has proven to improve the safety of care delivered to our oncology patients.
Lesley Tucker RN ~ Labor and Delivery Clinical Supervisor ~ Northside Hospital
Lesley has worked as an L&D Nurse since 1989. She started her career at DeKalb Medical Center. After 5 years there, she transitioned to working in a private practice with 2 physicians that offered home deliveries to low-risk mothers. Lesley joined Northside Hospital in March 2001. She initially started working in a PRN position, but within the first year, she filled the role of Charge Nurse 7p-7a. She currently serves as one of the Clinical Supervisors in Labor and Delivery. As we began to increase our staffing with significantly more new graduate Nurses, Lesley saw an opportunity to offer support and more education to these nurses. Initially, this support was an informal dialog during the course of the shift worked. She discussed possible scenarios that can and will be seen in L&D. Lesley asked them,” What would be the correct actions to take? What should not take place?” Lesley also found that through these discussions, the experienced nurses became more involved in coaching and mentoring the new grads. In January, Lesley put this into a structured format. She developed the ‘OB CRISIS DRILLS’ manual and the process for implementation.
Alanna Breckenridge, Pharm D. ~ NSH Forsyth Transition of Care Team Pharmacist ~ Northside Hospital
Alanna has been a pharmacist at Northside Forsyth for ten years. She started her career as a float pharmacist, working in all areas of the department, and on multiple units. Her attention to detail and clinical expertise quickly made her a favorite among the other ICU pharmacists and nursing staff. She eventually accepted a full-time role in 2012 as the primary dedicated unit-based pharmacist in ICU, covering a very busy 24-bed critical care unit as the sole pharmacist. Despite her patient care workload she managed to be an active participant in multiple ICU quality initiative projects including improving delirium assessment and prevention, implementation of Critical Care Glycemic Control Guidelines, and revision of the Therapeutic Hypothermia guidelines. When she left to join TOC she was replaced with 2 pharmacists! In 2015 Alanna was selected to be a part of the Transition of Care pilot project as their dedicated Clinical Pharmacist due to her excellent knowledge base, compassion, physician collaboration, and communication skills. Alanna diligently pursued any and every resource to ensure she was as knowledgeable and qualified as possible to take care of her patient population, including receiving her Board Certification in Geriatric Pharmacotherapy from the Board of Pharmacy Specialties… a title held by no other pharmacist in our organization. Since Alanna works with the patients both inpatient and post-discharge she has witnessed the medication errors that can occur. Alanna has worked diligently on this complex problem at a multitude of levels and with various key stakeholders. She has been a patient safety champion, working tirelessly to correct the medication lists for our TOC patients, and to impact change at the system level. Her passion and efforts around an accurate medication list and proper medication adherence reach far and wide beyond the patients we serve via the TOC program. She truly represents an exceptional commitment to staff education, patient safety and family engagement in the medication reconciliation process!
Leslie Martin, RN, Manager ~ Imaging Services ~ Kingman Regional Medical Center
On July 20, 2018, Leslie Martin received the Josie King Hero Award. Leslie proactively looks for patient and staff processes that need improvement and doesn’t hesitate to initiate coaching and teaching when she sees an opportunity. A recent example of improving teamwork and communications was her work to make sure the processes and protocols were in place and the staff was trained in order to start scanning pacemaker patients in MRI. She has also worked with Quality Management, Ultrasound and our nursing managers to improve the checks and balances for screening para and thoracentesis patients for medication contraindications before these exams. Leslie was integral in starting up our morning huddles with the radiologist and modality representative. Whether it is an imaging exam that we perform 1,000 times or just a few times a year, Leslie’s focus and concern for patient safety have improved the overall culture of patient safety at KRMC.
Crystal Brown, Hospice RN ~ Kingman Regional Medical Center
Crystal Brown received the Josie King Hero Award on July 20, 2018. There are many stories of Crystal being an amazing Hospice RN to patients and families. She always takes extra time to ensure the patient’s family is comfortable with the comfort medication that is prescribed, advocating for the patient and family when they want to make changes to the pain medication protocol. Examples of Crystal’s patient care and concern are massaging lotion into patients’ extremely dry skin, ensuring patients are occupied with things to do within sight of the nurses’ station, walking with patients in the garden, and she has even been known to decorate patients’ rooms with cute messages to remind them to be safe. Even when Crystal has a million other things to do, she is always trying to create something special for her patients and their families up to their very last moments on earth. She is a ray of sunshine for our Hospice patients and families in their darkest hour. She is definitely a hero.
Miranda Franklin, RN ~ Northeast Alabama Regional Medical Center
Sylvia Bajek, RN ~ UPMC Hamot
Sylvia Bajek is a nurse at UPMC Hamot’s Operating Room. Sylvia noted during the time-out that the consent on the chart indicated a different laterality than the History & Physical. Sylvia spoke up during the time-out process and she, along with the surgeon, investigated the discrepancy and confirmed the proper side before surgery. Sylvia’s attention to detail prevented the possibility of an adverse event for the patient.
Aaron Julian and Steve Medvis ~ UPMC Hamot
Aaron and Steve are transporters at UPMC Hamot. During a routine transport of a patient to the Radiology Department, they noticed that her condition changed en route. The patient went from being talkative to not being able to speak or look at them. Aaron and Steve realized something was wrong and called a Rapid Response Code. The Code team evaluated and took over the care of the patient. Aaron and Steve’s close attention to this patient during the transport helped them recognize when her condition changed and allowed her to get the care she needed instantly.
Mary Beth Hubbard, RN ~ UPMC Hamot
Mary Beth Hubbard is a nurse at UPMC Hamot’s Medical Intensive Care Unit. She was caring for a patient that had an order to receive an IV antibiotic, Zosyn. Mary Beth scanned the medication and also performed the five rights of medication administration – right patient, right drug, right time, right route, and right dose. During this process, Mary Beth noticed that the label on the solution bag and the label on the vial did not match. Mary Beth followed the proper procedure for medication administration ensuring that the patient received the right medication.
Josh Bickford, RN ~ UPMC Hamot
Josh Bickford is a nurse assigned to UPMC Hamot’s Trauma-Neuro ICU. Josh was told that his patient was having an irregular heartbeat throughout the day. Josh was curious about this since the patient was a young man with no previous cardiac history. He believed that the patient’s PICC line had moved and could be causing the irregular rhythm. Josh called the Attending physician and asked for a stat chest x-ray to confirm placement of the PICC line. The x-ray showed that the PICC line was malpositioned and needed to be pulled back. The Attending physician was notified and the PICC line was adjusted. The patient had no further episodes of an irregular heartbeat.
Dan Skrzypczak ~ UPMC Hamot
Dan Skrzypczak is a carpenter at UPMC Hamot. Dan was working on a job when he noticed an older gentleman who looked unwell. Dan asked the visitor if he was okay. The visitor could not speak and simply put his hands to his chest indicating that he had chest pain. Dan immediately called a Code Blue and told the gentlemen not to worry, and that help would be arriving soon. Dan stayed with the gentleman until the code team arrived. The team successfully resuscitated him and he was discharged from the hospital a few days later. Dan’s quick response to the situation was vital in getting the necessary resources to the visitor to save his life.
Bart Matson, DO ~ UPMC Northwest
Dr. Matson was caring for a patient who was just over 40 weeks pregnant. During an office visit, the doctor noticed that the fetus was in distress. Dr. Matson needed to transfer the patient to a hospital outside of her hometown; so he canceled his appointments for the day and traveled in the ambulance with the patient until she safely arrived at the hospital. The patient arrived safely and had a healthy baby.
Bobby Rodriguez ~ Carroll Hospital
Bobby works in our facilities department and goes above and beyond to assure that patient and families understand hand hygiene and isolation procedures. He also helps to remind our staff when they may miss a step!
When Bobby goes into a patient’s room to do work and the patient is on isolation, he takes the time to explain to the patient and their family why he is in isolation gear and why it is important for them. He also explains why the patient’s family should be following the same procedure. He also educates them on the importance of hand hygiene. If he sees a staff member not following appropriate infection control techniques (hand washing or isolation), he reminds them of the importance and then reports that back to our Infection Control Practitioner.
On September 28, 2015, Emily, a Peri-Op/PACU nurse at Carroll Hospital was the recipient of the Josie King Hero Award. Emily was selected as the Hero of the Year. Emily was working in Peri-Op one morning checking a patient in for surgery. The patient was scheduled to have a tubal ligation. By our policy, if a female patient had a negative serum pregnancy within 7 days prior to the surgery, we did not need to check a urine pregnancy prior to surgery. This patient arrived on the 7th day. By Policy, Emily did not need to do a urine pregnancy. Emily decided to do one anyway. It came back positive. In disbelief, she checked another and it again came back positive. This time she notified the surgeon who then ordered another serum pregnancy. This too came back positive. The surgery was canceled and the doctor spoke with the patient. The result of this, along with the safety of the patient and her unborn baby, was an immediate policy change that day related to female patients coming in for surgery. Now they check all females of childbearing age/ability regardless of whether or not they have a documented serum blood test.
Amy Alsante ~ Franklin Square Medical Center
Congratulations to Amy Alsante! Amy was awarded The Josie King Hero Award at Franklin Square Medical Center on Monday, November 17, 2014. MedStar has partnered with the Josie King Foundation to present a monthly award to an Associate who inspires colleagues through their work speaking up for patient safety. Amy was nominated by the team because of the presentation and work shared at the MedStar Quality and Safety Corporate Council. The work she is championing at Franklin Square Medical Center through tools and culture change inspired everyone around her. Amy was honored at a lovely reception with her coworkers and members of leadership.
Franklin Square was so excited about the Great to see the President and Board Chair at
award they made a photo cake! the event!
Katrina Dennis ~ Emory University Hospital
Donna Shifflett ~ Montgomery Medical Center
Congratulations to Donna Shifflett, a senior coder at MedStar Montgomery Hospital, who was recognized in December 2013 for catching a coding discrepancy that had a direct impact on a patient’s quality of life. When Donna noticed that a young woman had been diagnosed with a pulmonary embolism, but that the corresponding radiology report negated that diagnosis, she contacted the attending physician immediately alerting him of the contradicting information. The patient was subsequently called back in for evaluation, and when Donna’s suspicions were confirmed, the anticoagulant medications that had been started were discontinued.
Thanks to the mindfulness of Donna Shifflett, this young woman’s life was returned to normal. She is truly a leader and patient safety hero, and we look forward to hearing similar stories throughout MedStar.
Peter Pronovost ~ Sr. Vice President for Patient Safety and Quality, Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
Sorrel had the honor of presenting Peter Pronovost with the very first Hero Award. Peter has worked tirelessly for many years on the patient safety front. He has inspired healthcare providers not only throughout the United States but also around the world to create a culture of patient safety. Peter’s work continues to transform the healthcare industry making it better for us all. Peter is a hero to so many.