Hero Stories

Lisa Hetrick
Lisa Hetrick, Pharmacist – UPMC Hamot

At the time of this Good Catch, Chartwell had been compounding our NICU TPN fluids for about a week. The manual additives for each NICU TPN are sent by Chartwell over Teams (as a photo) for a Hamot inpatient pharmacist to approve for volume, medication, and concentration. In this particular event – the TPN had 6 manual additives. The heparin used for NICU TPN is preservative free l00units/ml. The photo received for pharmacy verification by Chartwell was a concentration of l000units/ml of heparin which is the incorrect product. Lisa quickly identified the discrepancy and confirmed the correct heparin concentration for this patient’s treatment. The process of Chartwell compounding NICU TPN required some adjustments in the early stages. In this situation, Lisa was able to identify an incorrect heparin product concentration and prevent injury to the patient. It’s a privilege to honor Lisa as a recipient of a Josie King Hero Award for her continued dedication to patient safety. Lisa, thank you for all that you do to build our culture of safety and for ensuring your patients receive the highest quality care.

Lisa Waugh
Carlisha Smith, RN, Surgery Department – UT Health, Tyler Midtown

Carlisha was recognized on September 29, 2023, by the Surgery Department at Tyler Midtown. David Williams and Keza Hisoler presented her with the Josie King Award. Thank you, Carlisha, for speaking up during an OR procedure and catching the error during the timeout. Your Good Catch resulted in keeping our patient safe. Congratulations!

Lisa Waugh

Malica Jackson, RN, Health Carousel

Malica’s Good Catch Story from her supervisor – Malica Jackson has been recognized several times with different awards at her hospital, for her excellent work. She saved a baby’s life recently when she was floated to the NICU. She had noticed the baby was not breathing normally and after she assessed her patient, she discovered her feeding tube had been placed incorrectly and was not going into the baby’s stomach. Instead, it was affecting the lungs. Based on her assessment and quick action, the feeding tube was able to be removed and replaced in the correct location. She has been nominated for the Daisy Award for all of her recognition from her coworkers and families of the babies she has worked with, and I believe she deserves the Josie King Hero Award.

Lisa Waugh

Lisa Waugh ~ Ambulatory Service Representative, Comprehensive Breast Center ~
UMass Memorial Medical Center ~ Q2 2022

Lisa Waugh has been named this quarter’s Josie King Hero Award recipient. The award was presented to Lisa at the Medical Center Leader Town Hall Wednesday, July 20 by Medical Center President Michael Gustafson, M.D.

Lisa was nominated for her tireless efforts working as a new patient coordinator to ensure that every patient has timely pathways to access necessary care at the Medical Center’s Comprehensive Breast Center. Lisa prioritizes each patient as an individual and looks for ways to reduce any and all barriers to care. Lisa closes the loop with referring providers, identifies process changes to improve every step, and ensures that patients safely get to their appointments. Referring practices and patients frequently call to recognize Lisa for the attentive care she provides and for ensuring that no patient has delays or gaps in care.

Jennifer LaFemina, MD, FACS, Division of Surgical Oncology, Department of Surgery, stated that “There is no one more deserving. We are so grateful Lisa is part of our team!”

Group Veterinarians, 20th Special Forces Group

Lee Palmer, Andrew Cox, Soren Rodning, Lisa Walker, and Dan Crowell are the Veterinarians for the 20th Special Forces Group. Their multifaceted approach to training, public health, preventive medicine, and patient interactions greatly enhances patient safety for all who interact with them. Through health inspections of food, water, and housing they prevent disease among both military and host nation personnel. Their teaching about zoonotic and exotic diseases enables other healthcare providers to recognize and treat conditions not commonly seen during normal operations in developed countries. Patient care provided by these Veterinary professionals furnishes outstanding examples of characteristics like attention to vital signs and, patient status, along with conscientiousness in performing procedural skills that translate easily and accurately for those providing care to human patients. One particular case involved a fluffy dog who was a therapy dog for a Soldier. Their efforts at ensuring safety for both the dog and the Soldier and in providing compassionate care were a shining example to those who had the privilege of working with them. The ability to evaluate and interact with non-verbal patients also helps human-patient providers learn how to do the same for non-verbal human patients and caregivers such as children and their parents, along with unresponsive patients and their families. The safety of not only individual patients but that of whole populations is significantly enhanced by the efforts of these consummate professionals. They embody the values and ethos of the prestigious Josie King Hero award.

Stacey Sawyer

Stacey Sawyer ~ Certified Pharmacy Technician ~ UMass Memorial Medical Center ~ Q1 2022

Stacey Sawyer, Certified Pharmacy Technician, has been named this quarter’s Josie King Hero Award recipient. The award was presented to Stacey at the Medical Center Quality and Safety Ground Rounds Tuesday, March 15 by Kimi Kobayashi, MD, Vice President and Chief Quality Officer, Center for Quality and Safety.

Stacey was nominated for identifying errors she found around documentation and ordering of medications during the medication reconciliation process. Stacey quickly established herself as an integral part of the University Campus Emergency Department (ED)’s team compiling patients’ at-home medication lists. Stacey has had several incredible great catches which have prevented potential adverse events for many patients arriving in the ED. These included identifying discrepancies in insulin concentrations and patients continued for medications to which they were allergic. Most recently, Stacey noticed a critical contraindication for a patient receiving Alteplase for an ischemic stroke. As the infusion started, the patient’s husband noted she was on Warfarin, but the international normalized ratio (INR) value was 1, causing Stacey to question why the INR was 1 and what anticoagulant the patient was actually on. Taking the initiative, Stacey found a note in the medical record indicating the patient had been taking a sample of Eliquis three days prior to presenting to the ED. The Alteplase was stopped, which potentially prevented a major hemorrhagic complication. After this incident, the Pharmacy Department identified a necessary way to document if a patient has been given sample medications. Stacey’s dedication to patient safety through thorough medication history list collection will avoid medication errors from reaching patients, exemplifying why medication reconciliation is important in the Medical Center’s goal of zero harm.

Kate Saunders

Kate Saunders ~ Director of Clinical Nutrition ~ UMass Memorial Medical Center ~ Q4 CY2021

Kate Saunders, Director of Clinical Nutrition, has been named this quarter’s Josie King Hero Award recipient. The award was presented to Kate at the Medical Center Leader Town Hall Wednesday, December 1 by Medical Center President Michael Gustafson, MD.

Kate was nominated for her tireless efforts to improve nutrition delivery to all patients, but with an added focus on the critically ill at the Medical Center. She has partnered with all levels of staff on initiatives that focus on better delivery decisions about enteral (introducing nutrients through a tube into the stomach or small intestine) nutrition which reduces complications of critical illness, most notably pressure injuries. Kate’s specific driving efforts include Intensive Care Unit pre-op feeding management, the development of an assessment and monitoring of enteral nutrition guidelines, and an improvement in the accuracy of documented enteral nutrition. Her continual efforts demonstrate her commitment to excellent patient care and are another testament to the organization’s goal of zero harm.

Kimi Kobayashi, MD, Vice President, and Chief Quality Officer, Center for Quality and Safety, celebrated Kate’s work by saying, “Such a deserving winner. We’re lucky to be able to partner with you on so many different initiatives.”  Kim Barry, Vice President, Patient Care Services, added, “Kate always keeps patient safety and comfort as a top priority. Well deserved!” And Michelle O’Rourke RN, Senior Director, Critical Care Services, capped it with, “I consider myself so lucky to have you as a partner in all our efforts that we have put forth to improve nutrition delivery to our critically ill patients and all our patients at the Medical Center.”

Thea Nolan

Thea Nolan, PA ~ Interventional Radiology ~ UMass Memorial Medical Center ~ Q3 CY2021

Thea Nolan, Physician Assistant from Interventional Radiology Services, has been named this quarter’s Medical Center Josie King Hero Award recipient. The award was presented to Thea at the Leadership Town Hall on September 1, 2021, by Michael Gustafson, MD, President.

Thea spoke up and escalated a concern that she saw regarding implantable ports and the issues of extravasation from the ports patients were experiencing. This escalation led to an investigation and discovery that UMass Memorial Medical Center (UMMMC) was seeing issues with ports from a certain lot number. UMMMC filed formal FDA events to notify the agency about our concern for defective ports. This was also escalated with the device manufacturer which eventually led to a recall by the company. UMMMC recently received a certificate from the FDA commending the organization on how our early reporting of the issue led to a national recall and helped to prevent harm in other institutions.

Thea’s courageous actions to escalate a concern that she had to protect her patients is a great example of the power of speaking up for patient safety and how it can have a tremendous impact – not just for UMMMC patients but also for patients nation-wide. In doing so, it allowed UMMMC to react to the issue faster by quickly getting replacement ports and preventing harm to patients on a grand scale. This prevention of significant patient harm, particularly to those cancer patients that have ports is a testament to the organization’s goal of zero harm.

Robert Ramirez

Robert Ramirez, Interpreter ~ Interpreter Services ~ UMass Memorial Medical Center ~ Q2 CY2021

Robert Ramirez, Medical Interpreter from Interpreter Services, has been named this quarter’s Medical Center Josie King Hero Award recipient. The award was presented to Robert by the Center for Quality and Safety at the Quality Grand Rounds on June 8, 2021. Robert was nominated for his ongoing dedication to providing linguistically and culturally sensitive, equitable care to our non-English-speaking patients. Without the use of a qualified interpreter, the medical staff could run the risk of committing errors in communication which could then impact the quality and safety of care delivered. This was exemplified in the execution of a complex language access plan for one of our patients during their hospitalization in our DCU Field Hospital during the COVID epidemic. Robert identified a patient that spoke an uncommon language which does not have many qualified interpreters. He went above and beyond in daily coordination between qualified interpreters and this patient’s medical/nursing teams, which allowed for a successful outcome for this patient. Rob always goes the extra mile for EVERY patient and bridges gaps that exist beyond language and culture. He has an intangible knack for assessing fundamental human needs and addressing them with the kindness, realness, and attention that they deserve, thus creating a culture of safety and setting an example for others.
Kimi Kobayashi, MD, MBA, SFHM, VP, Chief Quality Officer celebrated Robert’s work by saying, “Thanks, Robert for all that you do to promote quality and safety!”.

UMass Memorial Medical Center ~Q4 2019 through Q1 2021 ~ Recent Hero Award Recipients
June Boldt

June Boldt ~ New Wing Unit Secretary ~ United Memorial Medical Center (2/2021)

June is constantly checking and rechecking consent and MOLST forms for all of our patients besides doing her normal duties. She is always catching errors and teaching the nurses and physicians how to properly fill out the advance directives and consent forms. June is never afraid to have these forms fixed to properly care for our patient’s safety. June continuously listens to patients and families, improving communication and teamwork. June strives to create and strengthen a culture of safety at UMMC and Rochester Regional Health. June has been a hero to our department and all of United Memorial for years and is very deserving of this award.

Elizabeth Isaac

Elizabeth Isaac ~ Medication Safety Officer ~ UMass Memorial Medical Center | Department of Pharmacy ( 4th Quarter 2020)

Elizabeth Isaac, Medication Safety Officer in the Department of Pharmacy, has been named this quarter’s Medical Center Josie King Hero Award recipient. The award was presented to Elizabeth by the Center for Quality and Safety the Quality Grand Rounds on December 8. She received the award for being “a tireless advocate for medication safety.”

Elizabeth was nominated for her work to organize and lead many of our critical medication safety efforts that touch patients and have had a tremendous impact in driving a culture of safety. She was commended for being an exemplar in designing systems to be as safe as possible. And she is revered by her peers as an expert on medication safety and for inspiring them to be excited about medication safety work.

“Liz has been a tireless advocate for medication safety,” said Kimi Kobayashi, MD, MBA, SFHM, Chief Quality Officer and Vice President, Center for Quality and Safety, Medical Center and Medical Group. “She is an expert on this topic both from a pharmacy perspective as well as from an informatics perspective. She has led and organized many of our critical medication safety efforts. She has just the right balance of being passionate about improvement while also not being so dogmatic to become cynical or negative. We are truly lucky to have her in this organization.”

Carol Crockett

Carol Crockett ~ Civilian Educator ~ National Guard Unit (10/2020)

Carol Crockett’s professional life and career embody patient safety. She is an educator, mentor, and role model who integrates patient and provider safety into every aspect of her teaching, and her life. Carol is a Flight Paramedic, Critical Care Paramedic, and Paramedic educator who covers the full spectrum of care; including pre-hospital, tactical, emergency, and community paramedicine. Throughout the course of her decades of experience, she has influenced and coached multitudes of pre-hospital providers and has always kept patient and provider safety at the core of her life and practice. Carol’s ability to impart her wisdom and insight has positively guided multiple generations of paramedics and the patients they care for. Her unwavering dedication to keeping safety at the center of her teaching is a testimony to a commitment that was formed very early in her life and training. Carol’s distinguished career has contributed significantly to the improvement of pre-hospital patient care and safety for both patients and providers. We in the 20th Special Forces Group are confident that her efforts will have an impact well into the future by those she has taught and guided.

Staff-Sergeant Ryan “Pete” Taylor

Staff-Sergeant Ryan “Pete” Taylor (3/2020)

Staff Sergeant Pete Taylor’s enduring commitment to patient safety recently manifested itself when he took the initiative to plan, coordinate, and implement training for his unit that was forward deployed to an austere theater of operations. He implemented a robust training program oriented to enhancing provider awareness and improving patient outcomes – especially for critical care patients. This training has directly enhanced patient and provider safety for the unit when operating in a reduced resource environment. Pete’s profound insight let to a unique blend of full-spectrum medicine that had patient safety integrated throughout all aspects of patient care.

COL (Dr.) Dan Godbee

COLONEL (Dr.) Dan Godbee (3/2020)

COL Godbee has been a patient advocate and ardent patient safety promoter throughout his over four decades of military and medical service. He uniquely combines the characteristics of engineering and medicine from his vast educational and experiential background. Having initial education and a career in engineering enables Dr. Godbee to understand and implement objective analytic techniques into his practice of medicine. He understands how to use and interpret tools like root cause analysis and error identification and prevention to produce better methods of studying and generating policies and procedures that enhance patient safety. As a practicing emergency physician and EMS Medical Director, Dr. Godbee is in a position to impact both individual patient care and population-level medical practice; and he consistently places patient and provider safety at the top of his priorities. In his military role, COL Godbee again functions as both a direct patient care provider and a medical policymaker. His extensive background as an enlisted special forces medic for over 20 years gives him an outlook where he consistently places the patient at the center of all interactions, and their safety above all other considerations.

Staff-Sergeant Michael Share

Staff-Sergeant Michael Share (1/2020)

Staff Sergeant Michael Share has served almost twenty years of military service as a trusted medical provider starting voluntarily with some basic military medical training as a first responder with Combat Life Saver (CLS) training and early on was inspired to rise through the medical model of health care delivery.  His clinical experience now spans the continuum from fully qualified front-line military combat medic to hospital-based critical care as a Registered Nurse.  Mike’s ceaseless drive for further training and acquiring knowledge has helped ensure superb treatment for numerous patients throughout his years of clinical interactions.  Coupled alongside his desire to educate patients comes his natural talent for genuine connection with the patient’s worldview and provides truly holistic treatment plans that not only the patient but also the patient’s family values as well.

This comprehensive approach to the medical treatment model demonstrates Mike’s devotion to the healing of the whole patient and their experience under his care or under a more collaborative model of approach in which he is participating.  His positive outlook on the delivery of effective patient care is focused on the patient’s safety as an overarching concern.  This single-minded principle is articulated in all activities of the patient’s care and is clearly on display whether in a forward-deployed environment or the county hospital where he has made noted contributions going beyond compassionate direct patient care.

Since his initial inspiration in medicine was sparked in a basic military-medical course, his passion comes in the form as an educator where he had taken the next step of becoming a credentialed American Heart Association instructor.  In this capacity, Mike’s ability was elevated to educate fellow civilian and military medical providers as an instructor in the continental United States for almost a decade.  Later on, he was truly reaching the next level with unique military opportunities to instruct civilian foreign or local nationals and military coalition forces overseas with varied curricula ranging from promoting community health-based initiatives to basic and even more advanced healthcare practices for applicable medical providers.  It is Mike’s journey through a career in medicine that displays the delivery of compassionate and effective patient care by hand, heart, and mind.

CPT Alex Navarro

Captain Alex Navarro, Physician Assistant ~ Florida battalion (7/2019)

Captain Alejandro Navarro has served as a physician assistant in both military and civilian environments. He has shown a dedication to patient safety throughout his career as a provider. As a PA student, Alex learned early the importance of avoiding medical errors. During his rotation with an ophthalmologist, he was scrubbed in to help with a LASIK procedure. As the laser technicians were reading off the settings required for the planned procedure, Alex noticed that the numbers were not entered correctly on the screen. Without hesitation, he voiced that they needed to verify the settings once again. The incident left a lasting impression, as Alex learned that a small lapse in procedures or judgment can have a grave impact on patient outcomes.

CPT Navarro started off his Army PA career with the Warrior Training Center, out of Fort Benning, GA. As the lead provider for the Warrior Training Center, Alex was tasked with providing medical clearances for hundreds of students from all services transitioning through demanding courses. Among the courses, was the National Guard’s only Ranger Training and Assessment Course (RTAC). Alex used his medical knowledge to review medical records and physical exams in order to preclude placing a person through the rigors of RTAC that had the potential of causing physiological harm. He diagnosed chronic and acute conditions that required further evaluation and was able to use his position to ensure students were received follow-up care once they left the courses. His efforts allowed for a reduction in injuries and appropriate care of previously undiagnosed conditions.

As a civilian provider, CPT Navarro has worked in both inpatient and outpatient settings, including a Level 1 Trauma Center. Alex has extended his efforts of avoiding patient errors by ensuring any events that could lead to a patient error are immediately addressed. All patients under his care are identified through multiple sources of information and a time out is performed whenever possible, in order to ensure the patients are receiving the treatment indicated. In the stressful environments of Emergency Medicine and Surgical ICUs, he has been able to establish himself as a patient advocate and perform above the standard of care. His dedication and willingness to voice concerns, have impacted patient care throughout his career as both a military and civilian physician assistant.

Kyle Upton

Kyle Upton, Nursing Assistant ~ University of Iowa Hospitals and Clinics (4/2019)

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.

Kyle Upton
Dr. Syed Ahmad ~ National Guard unit ~Florida (5/2019)

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 errors. 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 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 errors. 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 errors 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

Sara Chase, RN ~ LincolnHealth (4/2019)

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.

MSG Robert Kilgallon
Master-Sergeant Robert (“Rob”) Kilgallon (4/2019)

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

Colonel Dave Butler ~ First Military Recipient of the Josie King Award (2/2019)

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 service, Dave was a Special Forces Medic and became a Physician Assistant with the Army Special Forces.  He is a veteran of Vietnam, the Gulf War, and the Global War on Terror where he was part of the invasion of Afghanistan.  Dave has consistently provided the highest quality medical care even under the most austere conditions and in the most remote environments.  Along with his extensive military background, Dave has a large private practice where he owns multiple clinics and still manages to work full-time indirect patient care.  His clinics are located in areas of the community where they provide for a large number of underserved patients who would otherwise have had no access to medical care.  Dave is a true patient advocate, a patriot, and always prioritizes the safety and well-being of his patients.  Throughout his over four decades of both military and private medical practice, he has mentored and trained dozens of medics and professional level providers, and always inspired them to keep the patient at the center of their thoughts and focus.  To this day, Dave has been an example to multiple generations of medical personnel and a trusted advisor to operational leaders.  Even during combat operations in multiple war zones, Dave always prioritized patient safety and well-being and was an aggressive patient advocate.  In his private clinical work, he has diagnosed and treated some rare and exotic diseases that only the most astute of providers would have identified.  Often Dave’s penchant for patient safety has been manifested by him coordinating and implementing transfers of these un-common presentations from his primary care clinic directly to hospital in-patient status.  Due to Dave’s renowned and sterling reputation within the local medical community, his patients are able to receive expeditious care from consultants and sub-specialty providers.  Dave is routinely able to listen to the patient’s and family’s concerns and incorporate this information into a significantly better and more appropriate treatment plan.  Dave Butler is truly an example to everyone on how to provide the highest medical care in the most caring, compassionate, and safest environment.

Colonel Dave Butler

Darra Schmidt, BSN, RN, OCN ~ Atlanta Cancer Care, Alpharetta ~  Northside Hospital (11/2018)

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 to the infusion suite.  The utilization of the tool has proven to improve the safety of care delivered to our oncology patients.

Colonel Dave Butler

Lesley Tucker RN ~ Labor and Delivery Clinical Supervisor ~ Northside Hospital (10/2018)

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 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
Alanna Breckenridge, Pharm D. ~ NSH Forsyth Transition of Care Team Pharmacist ~ Northside Hospital (10/2018)

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

Leslie Martin, RN, Manager ~ Imaging Services ~ Kingman Regional Medical Center (7/2018)

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

Crystal Brown, Hospice RN ~ Kingman Regional Medical Center (7/2018)

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.

Crystal Brown

Bobby Rodriguez ~ Carroll Hospital (2/2016)

Bobby works in our facilities department and goes above and beyond to assure that patients 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 in 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.

Crystal Brown

Miranda Franklin, RN ~ Northeast Alabama Regional Medical Center (9/2016)

On September 21, 2016, Miranda Franklin received the Josie King Hero Award.  Miranda is the day shift charge nurse on Unit 8 (med-surg) at Regional Medical Center in Anniston, Alabama.  Miranda was caring for a patient who had recently been admitted with altered mental status.  Miranda noticed some very subtle changes in the patient’s level of consciousness, vital signs and lab work.  After talking with the patient’s family she diligently communicated with the primary care physician and consulting infectious disease doctor.  Miranda’s “good catch” and persistence hastened the consult, a diagnosis of meningitis and rapid, appropriate treatment.  The physician recognized Miranda’s skills as life-saving for a critically ill patient.

Emily Udseth

Emily Udseth ~ Carroll Hospital (9/2015)

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. 

Sylvia Bajek, RN ~ UPMC Hamot (11/2015)

Sylvia Bajek is a nurse at UPMC Hamot’s Operating Room. Sylvia noted during the time-out that the consent on the chart indicated 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 (11/2015)

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 (11/2015)

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 (11/2015)

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 the 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 (11/2015)

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 (11/2015)

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.

Amy Alsante ~ Franklin Square Medical Center (11/2014)

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.

Katrina Dennis

Katrina Dennis ~ Emory University Hospital (11/2014)

Congratulations to Katrina Dennis, RN, Unit Director of Unit 52 at Emory University Hospital Midtown! Sorrel had the honor of presenting the Josie King Hero Award to Katrina last week. Katrina was given this award in recognition of her leadership that has inspired everyone on her unit. Her passion for quality and safety is evident to all. Keep up the great work Katrina, Sorrel

Donna Shifflett

Donna Shifflett ~ Montgomery Medical Center (11/2014)

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

Peter Pronovost ~ Sr. Vice President for Patient Safety and Quality, Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine (11/2014)

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.