The Colorado Patient Safety Coalition is pleased to announce the winners of the 2002 Patient Safety Awards, presented at the "Do No Harm" Annual Conference on November 1, 2002:

Patient Safety Leadership Award

Presented to:  Community Hospital of Grand Junction, CO

Received by:  Mr. Randall Phillips, President and Chief Executive Officer.

High-quality healthcare requires excellence in many areas, medical practice, guest relations, and most importantly, patient-guest safety. This can only be achieved through an integrated culture of safety.

The leadership of Community Hospital recognizes that a “culture of safety” starts at the top, with them. The Board of Trustees and Senior Leadership have long been involved in safety initiatives and made safety a priority over 4 years ago. However, in 2002 they elected to make patient-guest safety a more deliberate, stated focus by the adoption of patient-guest safety as a “top priority” strategic initiative. The Board’s intention is to keep patient-guest safety a strategic priority focus well into the future. 

Community Hospital understands that environments where you “talk” patient-guest safety and “live” patient-guest safety are very different. Community Hospital “lives” quality and patient-guest safety through a culture of partnerships that promotes new ideas and open communication among and between all employees, physicians and volunteer Partners. This culture of Partnerships clearly defines each individual’s role and responsibility to ensure the safety of each patient-guest in the facility, through a process of orientation, ongoing education and performance review. Every Partner is responsible for improvement and for identifying areas to enhance patient-guest safety. Community Hospital’s Partners recognize that safety is an integral part of the larger picture of organizational quality and excellence.


Patient Safety Leadership Award

Presented to:  Kaiser Permanente Clinical Pharmacy Call Center

Received by: Dr. Dennis Helling, Pharmacy Administrator

A time of transition is a time of great risk for a patient's safety.  Kaiser Permanente of Colorado has recognized this, and has evolved a unique support system for new patients enrolling in their health plan.  New members are encouraged to call a clinical pharmacist who spends approximately 45 minutes discussing and reviewing the patient's current drug regimen.  The prescriptions are confirmed with the previous dispensing pharmacy, and discrepancies are resolved.

The Kaiser Permanente Clinical Pharmacy Call Center has studied the effectiveness of this program, and has found that:

*            11% of patients were on medications inconsistent with evidence-based national guidelines and changed to more appropriate therapy.

*             6% admitted non-compliance and were educated about the importance of their medications.

*             12% were taking medications that they no longer needed.  These were discontinued.

*             14% were identified as smokers and were provided information on smoking cessation.

*             100% had their medication allergy information entered into the electronic medical record and the pharmacy computer system.

*             26% were on medications that required laboratory monitoring which was ordered.

Projecting these numbers to the 30,000 new members who contacted the pharmacy call center in the last 3 years shows the dramatic effect that this process has had on protecting patients during this vulnerable period of transition.  The physicians and the patients have welcomed this intervention by the clinical pharmacist call center alike, as it reduces insecurity, extra work and confusion at the time of transition.

Patient Safety Leadership Award

Presented to:   Dr. Michael Dohm

Dr. Michael Dohm, orthopaedic surgeon, has been a tireless advocate for change in the areas of patient safety and quality improvement throughout his entire career. Dr, Dohm put his money and personal effort into the Western Slope Study Group that he founded in 1997. From its inception, the Western Slope Study Group has championed outcomes data collection and evidence-based practice in a collaborative, non-threatening environment dedicated to improving patient care and safety.

The Western Slope Study Group propagates the discipline of evidence-based practice through application of an evolving provider education model, developed by Dr. Dohm and his colleagues and termed KADRE:  Knowledge, Assimilation, Data collection, Reflection and Education.

For 10 years Dohm has voluntarily taught orthopaedics to Residents at St. Mary’s Hospital Family Medicine Residency Program. His services include: weekly Radiology Review, monthly Orthopaedic Conferences and a curriculum of active learning presentations. In 1999,Western Slope Study Group, under Dr. Dohm’s leadership, developed the Evidence-Based Medicine Conference delivered in Grand Junction to over 60 primary care providers. He presented: the E. A. Codman Lecture: Clinical Truth and Humbug.

Within his community, Dr. Dohm has brought together physicians and hospital administrators through the formation of discussion groups that have led to the recommendation of improved safety practices involving both clinicians and hospital staff…and from what we understand, his work is far from over!
 

Patient Safety Leadership Award

Presented to:   Colorado State Board of Medical Examiners

Received by:   Dr. Ned Colange, Board President and Chief Medical Officer of the Colorado Department of Public Health and Environment – and Susan Miller, Administrator, Colorado State Board of Medical Examiners

The BME has recognized the importance of preventing licensing problems rather than dealing with them only after they occur.  In it's January 2002 edition of The Examiner (the newsletter of the Board that is circulated to all licensees), the board began to publish anonymous stories of actual cases where they believe a systems problem may have been at fault for the problem. The initial issue focused on problems with communication; communication from a physician to a patient;

Communication with other physicians providing intermittent practice coverage; communication with other practitioners in a new care setting, etc.

The CPSC celebrates this new approach of the BME as it shares the issues that have caused problems with a licensee in such a manner that others may learn from the systems problems that others have experienced.  Hopefully this new approach will prove successful in preventing future errors, placing the patients of Colorado physicians at less risk for future systems errors.
 

Patient Safety Leadership Award

Presented to: Department of Veterans Affairs: Southern Colorado Healthcare System

Received by:  Ms. Cathy Hamilton, Patient Safety/Risk Manager

The Veteran’s Affairs Southern Colorado Health Cared System has shown leadership in its strong efforts to implement the protocols developed by the VA's National Center for Patient Safety. These protocols involve the analysis of specific events, and the application of root cause analysis to identify the human behaviors to modify, and barriers to safety that needs to be overcome. The Veteran’s Affairs Southern Colorado team has done a great deal to establish and encourage the deployment of the patient safety models to address specific issues here in Colorado – including the following:

• Anti Coagulant Monitoring Initiative: With the help of the Denver VA Pharmacy staff, a new "Anti Coagulant Monitoring Initiative" was developed to address specific problems that were identified here in Colorado.  The effort has resulted in the careful monitoring of the use of anti-coagulants for the VA’s southern Colorado patients.

• Managing Change: When the VA’s Ft. Lyon facility converted its focus to that of an outpatient care center, many existing patients had to adjust to the need to have appointments for their care - rather than walking in for "care on demand".  During his time, the southern Colorado VA developed a triage system to assure that this patients showing up for care on demand were appropriately cared for if/when needed.  This protocol recognized the potential for harm given the historical use patterns of the patient, and established a rational procedure to convert to an appointment system.

• Continuity of Care: A "Continuity of Care" initiative that focuses upon the appropriate communication between private health care facilities, emergency departments, and the VA system.  The VA team recognized that in making care transitions that valuable information was being lost.   Through the use of patient assessment forms and a minimum data set, the VA forwards information along with patients as they navigate the health care system, thus assuring that vital information is made available to practitioners wherever the care may be given.

Patient Safety Leadership Award

Presented to:  Dr. Wilson D. Pace

Dr. Pace has become a leader in our state in the emerging field of patient safety.  As a Principal Investigator for a federally funded multi year study, Dr. Pace has brought together a number of individuals and organizations in Colorado to focus upon how we may identify, analyze, and reduce errors in the area of ambulatory primary care. Through the research project that Dr. Pace leads (entitled “ASIPS” – Applied Strategies for Improving Patient Safety) the identification and reporting of occurrences with the potential to cascade into patient harm will be carried out on a large scale. 

This work is not easy.  As the leader of a Practice-Based Research Network, Dr. Pace (Wilson) has used his own political capital, intellect, and wit to involve over 600 clinicians, administrators, and researchers in this effort. The nomination that was received for Dr. Pace is an indicator of the respect that he commands in this area – and was signed by ten of his colleagues!

It is anticipated that Dr. Pace’s   leadership and hard work will result in the establishment of the Health Sciences Center, the Department of Family Medicine, the CareNet and High Plains Research Networks, and affiliated organizations as a patient safety resource within the Rocky Mountain West, and beyond.  Please join me in acknowledging Dr. Pace’s contributions.

Patient Safety Leadership Award

Presented to:  Association of periOperative Registered Nurses

Received by Ms. Julie Massaro, VP of Marketing and External Relations

The Colorado Patient Safety Coalition (CPSC) is pleased to present a 2002 Colorado Patient Safety Award to the Association of periOperative Registered Nurses (AORN). To address the growing public and professional concern about patient safety, AORN created the AORN Presidential Commission on Patient Safety. Commission members determine strategies and initiatives that will place AORN in the forefront of patient safety issues in the perioperative setting, and will support organizational efforts to coordinate a common venue for dialogue among the various members of the multidisciplinary perioperative team. Through its patient safety initiative and Patient Safety First program, AORN is identifying, collecting, and developing clinical and educational resources to help perioperative nurses ensure safe, quality patient care. For example AORN has developed the following member resources:

1.   A Patient Safety First web site designed to provide ready access to resources related to patient safety in surgical settings

2.   A safety consult e-mail address for members to offer their comments and suggestions or ask for advice about safety in surgical settings.

3.   A patient safety “hotline” with toll-free access for members to call with their patient safety questions.

The CPSC recognizes the innovation and commitment of AORN to support perioperative nurses in Colorado and nationally in their efforts to provide quality patient care by presenting this 2002 Colorado Patient Safety Award to the Association of periOperative Registered Nurses (AORN).

Congratulations, all!

The Coalition would also like the recognize the the following individuals for their work on the Awards Committee:

Committee Chair:    Donna Kusuda

Committee Members:  Mark Levine, Paul Harshman

Technical and Moral Support:   Mary Fletcher, Linda Kanamine