Celebrating Innovation and Excellence in Patient Safety

Published Saturday, December 21, 2024 from the desk of John Chessare MD , MPH, President and CEO of GBMC HealthCare .

Last week, I shared my recent experience at the Institute for Healthcare Improvement ( IHI ) Forum. This week, I am excited to highlight the exceptional efforts of GBMC's Quality Improvement team, whose work was presented during the forum. Experts from across the world submit their work for consideration, so being selected is quite an honor!  

Transforming Patient Safety with Technology and Teamwork 

Our team's presentation, titled "Leveraging Technology to Decrease the Incidence of Pulmonary Embolisms (PEs) and Deep Vein Thrombosis (DVTs)," chronicled GBMC's success in reducing preventable PEs and DVTs by an astonishing 94% since 2019. This achievement demonstrates the power of a multidisciplinary approach, advanced technology, and evidence-based protocols in driving meaningful improvements. 

Some key strategies included: 

• Real-time dashboards in our Electronic Health Record (EHR): Empowering clinicians with immediate insights into patient risks and care opportunities. 
• Standardized order sets: Ensuring consistency in prophylaxis delivery. 
• Evidence-based protocols: Incorporating guidelines for risk assessments, appropriate timing and dosing of pharmacologic prophylaxis, and patient education to ensure adherence. 
• Proactive provider feedback systems: Promoting adherence to best practices. 
• Patient-centered education: Encouraging participation and compliance from those in our care. 

Through collaboration among clinicians, IT experts, and patient educators, our team has set a benchmark in patient safety—one that aligns seamlessly with GBMC’s vision: “To every patient, every time, we provide the care we would want for our own loved ones.” 

Thank you and congratulations to Joseph Fuscaldo, MD, Medical Director of Quality Improvement; Ryan Curran, Outcomes Manager; Marge Noel, Epic Liaison; and Ryan Perrott, PharmD, Epic Analyst, who led this effort and shared these insights at the IHI Forum, inspiring other organizations to replicate our success! 

Recognizing Everyday Excellence 

At GBMC HealthCare, we foster a culture of safety by encouraging early and frequent reporting of incidents and near misses. Guided by the principles of just culture, our focus is on learning and improvement—not blame. Rather than hiding mistakes, we view them as opportunities to identify and address system weaknesses, preventing future failures. 

In this spirit, I’m proud to celebrate Roxanne Sharkey, RN, as a recent recipient of the Great Save Award from our Quality and Patient Safety team. Roxanne exemplifies the “questioning attitude” that is key to high reliability. 

While reviewing a pediatric patient's discharge summary, Roxanne identified a potentially harmful prescription dose. Thanks to her diligence and teamwork with Dr. Rachel Plotnick, the error was corrected, and the patient’s family was guided toward safer pain management. This proactive approach not only prevented a potential overdose but also ensured the family felt supported during a stressful time. 

Thank you, Roxanne, for your diligence in keeping our patients safe! And thank you to all our staff for your vigilance in reporting incidents so we can continue to learn and improve.