December 2016
Safety News is a bimonthly e-newsletter providing the latest news and tips for patient and employee safety at Johns Hopkins All Children's Hospital. Click the links on the right side to learn more about each of the topics.

A Message from Dr. Mueller
Brigitta Mueller, M.D., M.H.C.M., vice president of medical affairs and chief patient safety officer

Safety is our culture. As this newsletter shows, safety permeates many aspects of our daily activities. Through Solutions for Patient Safety, we have learned that safety is the cornerstone of high quality health care. We have made great strides in our culture of safety. I am pleased to see more and more HERO reports where a team member reports a mistake they themselves made, because “if it happens to you, it can happen to anyone!” We know that everyone is trying to do their best, but errors do happen when humans are involved (and sometime when computers are involved, too) and the only way we can learn from such incidents is when we talk about them.

However, health care systems, including our own, still have more work to do. The Joint Commission emphasizes that a safety culture depends on three elements: trusting, reporting and improving. In order to report, one has to trust that you will be heard and will not experience adverse effects from reporting, and also that you will see changes happen based on your reporting. Our behavior is the most crucial aspect of our culture of safety. Intimidating and disrespectful behaviors disrupt this culture and prevent the collaboration, communication and teamwork required for safe and highly reliable patient care.

Disrespect is not limited to outbursts of anger that humiliate a member of the health care team; it can manifest in many forms (as listed in the Joint Commission Patient Safety chapter):

Inappropriate words (profane, insulting, intimidating, demeaning, humiliating or abusive language)
Shaming others for negative outcomes
Unjustified negative comments or complaints about another provider’s care
Refusal to comply with known and generally accepted practice standards, the refusal of which may prevent other providers from delivering quality care
Not working collaboratively or cooperatively with other members of the interdisciplinary team
Creating rigid or inflexible barriers to requests for assistance or cooperation
Not returning pages or calls promptly

An Institute for Safe Medication Practices survey with 4,884 respondents, including nurses, physicians, pharmacists, and quality/risk management personnel, found that:

73 percent witnessed negative comments about colleagues or leaders during the previous year
68 percent reported condescending language or demeaning comments/insults
77 percent said they had encountered reluctance or refusal to answer questions or return calls
69 percent had encountered impatience with questions or phone hang-ups
Nearly 50 percent indicated that intimidating behaviors had affected the way they handle medication order clarifications or questions, including assuming that an order was correct in order to avoid interaction with an intimidating co-worker
11 percent said they were aware of a medication error during the previous year in which behavior that undermines a culture of safety was a contributing factor

Let’s make sure this is not the case here at Johns Hopkins All Children’s. Let’s live our core values of respect and collegiality and act as role models. This will create the safest environment for our patients, families, visitors and staff.

Brigitta U. Mueller, M.D., M.H.C.M.

Summary of Healthcare Quality Week, International Infection Prevention Week, Research Symposium and Quality Awards

Healthcare Quality Week and International Infection Prevention Week occurred October 16-22. This year, in addition to celebrating both weeks, we collaborated with the annual JHACH Research Symposium and combined efforts to display and present the quality improvement (QI) projects in conjunction with research projects completed over the past year.

Employee Health and the Health Department joined us to kick off the week and provided flu immunizations to employees, giveaways and educational handouts. Dr. Allison Messina gave a midweek presentation on cytomegalovirus (CMV). On October 20 – 21, ten Quality Improvement (QI) projects posters and 38 research project posters were displayed and presented. More than 70 employees came to view and hear about the projects and then vote for best hospital and local QI projects and best research abstracts for basic, clinical/translational and trainee-initiated research. Congratulations to this year’s winners:

Best Hospital-Wide Quality Improvement Project

Standardizing Total Parental Nutrition to Reduce Errors
Fauzia Shakeel, MD; Jacquelyn Crews, MD; Russell Sayles, PharmD; Jeanne Farrell, RD; Danilo Escoto, MD; Stacey Stone, MD; Melanie Newkirk, RD; Oscar Winners Mendizabal, MD; Michelle Smith, MD; Paola Dees, MD; Elena Rueda-de-Leon, MD; Sean Butler, MD; Jazmine Mateus; Kathy Renn, ARNP; and Denise Remus, PhD, RN.

Best Unit/Local Level Quality Improvement Project
Growing the Herd: Improving Immunization Rates in Primary Care
Rachel Dawkins, MD (physician lead); Christine Moore, ARNP (clinical lead); Bob Warfield, RN and Vicki Dunn, RN (administrative leads); Melissa Brinn, MD; Heinz Chavez, MD; Raquel Hernandez, MD; Jane Sando, MD; Kristen Maddox, LPN; Edgar Arellano, LPN; Sherri Hess, LPN; Angela McKeown, MA; Janelle Carter, MA; Sade Campbell, OA; Lori Avery, OA; Carol Ventura; Dipti Amin, MD; and all of the JHACH pediatric residents.

Best Abstract – Basic Research
Immune Checkpoint Targeting to Improve Immunotherapy for Neuroblastoma
Myrna L. Ortiz-Ruiz, MS; Krithika Kodumudi PhD; Amy Weber and Shari Pilon-Thomas, PhD.

Best Abstract – Clinical/Translational
Increased Risks of Both Bleeding and Recurrent Thromboembolism with Intravenous Enoxaparin When Compared to Subcutaneous Enoxaparin Twice-daily for the Treatment of Acute Thromboembolism in Critically-ill Infants and Children
Adrian L. Turner, PharmD; Amanda Memken, PharmD; Alfred Asante-Korang, MD; Ernest K. Amankwah, PhD; and Neil A. Goldenberg MD, PhD.

Best Abstract – Resident/Fellow Initiated Research
Staged Resection of Large Supratentorial Brain Tumors in Infants in Young Children with Interval Neoadjuvant Chemotherapy Allows for Maximal Safe Resection
Rajiv R. Iyer, MD; Stacie L. Stapleton, MD; Carolyn C. Carey, MD; Gerald F. Tuite, MD; George I. Jallo, MD; and Luis F. Rodriguez MD

U.S. News & World Report Survey Kickoff

The U.S. News & World Report Best Children’s Hospitals survey kickoff meeting will be held December 14. Ten pediatric specialty teams and support staff from JHACH will begin the process of gathering and reviewing information to be included in the survey which will be submitted in March 2017.

MOC Portfolio Sponsor Status Renewed

Johns Hopkins All Children’s Hospital received approval from the American Board of Pediatrics (ABP) for renewal of our application as a Maintenance of Certification (MOC) Portfolio Sponsor. JHACH has been a portfolio sponsor since the fall of 2014; the renewal is through fall 2018.

For physicians who are involved in quality improvement initiatives, projects are reviewed for specific criteria set forth by the ABP. Then, as a portfolio sponsor, we review and can approve the projects for MOC part 4 credits to be used toward board recertification.

Being a portfolio sponsor helps organizations reduce the costs and burden of applying for approval for individual projects. More importantly, it supports and encourages physician involvement in quality improvement projects. To learn more about current MOC projects or how to submit a project for MOC part 4 credit, contact Kathy Renn at

2017 Safety Culture Assessment

The Safety Culture Assessment (SCA) Survey will take place January 17 – February 28, 2017. This impactful survey gives team members the opportunity to be heard and to help us promote a safe and healthy workplace. Watch for more information early in the new year.


In June 2016 we completed Central Line Maintenance Bundle Competency sessions for all nursing staff members at all points of inpatient care. We did this to improve the reliability of central line care processes so that we can reduce the risk of patients acquiring a central line-associated bloodstream infections (CLABSI). We have measured bundle compliance post training to assure that the training sessions were effective in standardizing care. Overall results have been positive with staff displaying increased skills and decreased variation with central line care processes.

We continue to support central line competency with Intentional Rounding. Each week a designated educator group rounds on the units with WYNK (what you need to know) sheets as guides to support staff with continuing education for central line care. This supportive team is working closely with staff who care for lines to provide important safety information such as identifying line types, line labeling tips and other useful knowledge to further improve central line care.

The next phase in our CLABSI reduction journey will involve identifying a pilot unit with local leadership involvement, safety coach input, training of unit staff on error prevention and care bundle measurement, with real time analysis of failure and accomplishments so that clinical staff closest to central line care can note what variations in care are occurring and make improvements in real time.

Infection Prevention: Is it Flu or Allergies?

Reprinted from APIC (Association for Professionals in Infection Control and Epidemiology) “Infection Prevention and You” news release

Fall is here. Cooler temperatures fill the air. The change in season also brings illnesses that cause the eyes to water, itch, and become puffy. Soon sniffles, sneezes, and sore throats develop. Are these allergies or is this the flu? Knowing the key differences will help in deciding the best treatment.

What causes allergies and flu?
Allergies are the body's response to allergens such as dust, pollen, pet dander, cigarette smoke, or food. Allergies are not contagious and are not caused by a virus. The flu is contagious and is caused by a virus.

What are the symptoms of allergies and flu?
Allergies occur commonly during the spring through the fall seasons. Symptoms last as long as there is an exposure to the allergen. These symptoms include sneezing, sore throat, coughing, runny nose, and congestion. Allergies may cause mucus that is clear and thin. Other symptoms are itchy, watery, and puffy eyes. In some cases, a rash or hives develop. Allergies do not cause a fever.

The flu causes fever with temperatures of 100-102 degrees Fahrenheit. Symptoms of the flu include chills, cough, sore throat, runny and stuffy nose, headaches, severe muscle or body aches and pains, and fatigue. Other symptoms such as vomiting and diarrhea are more common in children. Flu symptoms occur during the flu season, which is from October through May. On average, flu symptoms last 1-4 days.

What are the treatments for allergies and flu?
To treat allergies, avoid allergens. The doctor may prescribe antihistamines, steroids, or decongestants. To treat the flu, get plenty of rest and stay hydrated by drinking fluids. The doctor may prescribe an antiviral medication.

What are the ways to prevent allergies and flu?
Allergies can be prevented by avoiding allergens such as dust, pollen, pet dander, cigarette smoke, and food. The most effective way to prevent the flu is to get the flu vaccine every year. A flu vaccine is needed this often because flu viruses are constantly changing. It’s not unusual for new flu viruses to appear each year. The flu vaccine is formulated to keep up with the flu viruses as they change. Washing hands often, avoiding close contact with someone who has the flu, and covering the mouth when coughing or sneezing are other ways to prevent the flu.

Additional resources
APIC consumer alert—Why should I get a flu shot?
CDC—Keys facts about influenza (flu)
CDC—Flu symptoms and complications
AHA—United against the flu

Summary of Patient Blood Management Prevention Week

Patient Blood Management Awareness week was engaging and informative for hospital staff. The week kicked off with a Family Feud roaming cart for a battle of clinicians’ knowledge. More than 60 people visited an information awareness table and left with a treat after they read at least one “fun fact” about how blood management affects our patients at JHACH. The week ended with a presentation on platelets and how our future practice could greatly impact the overall initiative to improve outcomes while avoiding transfusions. Everyone who engaged in being “Blood Smart” was entered to win a Fitbit. Congratulations to the winner, Christine Petsalis, patient service coordinator in Kids Home Care.

Solutions for Patient Safety Error Prevention Tool Box – “ARCC”
The “ARCC” tool promotes the behavioral expectation that “Everyone Makes a Personal Commitment to Safety – We do the Right Thing.” The goals in communicating are to be clear and concise and model this behavioral expectations. We recommend using ARCC when a team member wants to check on information or if you are coaching someone:

A = Ask a question
R= Request a change
C= Concern- voice a concern
C= Chain of command

Please feel free to “ARCC” if you have a question or something doesn’t make sense that was communicated to you.

SPS and CMS Partnership = HIIN initiative
The Centers for Medicare & Medicaid Services (CMS) recently awarded funds to 16 national, regional or state hospital associations, quality improvement and health system organizations to continue progress toward a safer health care system. Solutions for Patient Safety (SPS) is one of the 16 organizations that received this award. SPS represents over 100 children’s hospitals nationally and is the leader in pediatric patient safety.

JHACH is a participating member of SPS since July 2015 and joined its Culture Wave 5 in January 2016 as a commitment to actively build our culture of safety. Their goal is to create a universally safe and healing environment for all children who need care. JHACH is urgently driven to reduce and then eliminate serious preventable harm.

Through CMS’ Partnership for Patients Hospital Improvement Innovation Network (HIIN) initiative, SPS will begin to focus on C. difficile infection and antimicrobial stewardship in 2017. The following year, the network will begin to focus on acute kidney injuries and sepsis.

The partnership will continue to work to improve current initiatives in adverse drug events, catheter-associated urinary tract infections, CLABSIs, falls, peripheral intravenous infiltration and extravasations, pressure Injuries, readmissions, surgical site infections, unplanned extubations, ventilator-associated events, and venous thromboembolism. JHACH is exited to participate in this partnership. For more information on this CMS announcement, click here.

If you are interested in joining in our membership with SPS, please contact Jasmin Matamoros at

Executive Safety Rounds: Reported Findings and Solutions
Executive Safety Rounds occur weekly throughout the hospital and outpatient areas. During rounds, staff are asked what safety concerns they have or “what keeps them up at night” regarding concerns in their workplace or anywhere on campus. Your voices are heard: all concerns are documented and tracked, then sent to the appropriate area for evaluation and resolution when possible. Here are a few resolutions recently completed following concerns that were reported in Executive Safety Rounds.

Added a new “push to open” wall button and new signage at the radiology exit and new signage to help parents and staff better navigate
Computer and phone cords/wires in CDRC offices were bundled and secured by maintenance to prevent possible trip/fall hazards
Patient information is now being printed on prescription labels in PACU to address a concern raised by staff that the previous labels could have been easily removed

Safety HERO
You reported it, and we heard it:

Thanks to Sharon Thomas from Environmental Services (EVS) for identifying and submitting a HERO report on the following safety concern: Sharon reported that on two floors of the OCC there was visual obstruction when she went to remove the EVS cart from a storage closet, which meant that she was not able to see whether patients (especially smaller ones) or families were in the corridor. Not only did Sharon report this, but she also proposed a solution of a hall mirror which was installed by the maintenance staff. The hallways are now safer because of Sharon’s attentiveness in reporting this concern. She saw something, said something and did something. We thank her for being a Safety HERO.

Friendly Reminder: New Way to Reach Security: Email
You can now reach the Security Department at with non-urgent questions, comments or concerns. Please use this email address for questions about parking, card readers, locking/unlocking doors, cameras, requesting security at special events and lost and found items. For badge requests, you should continue to use

Questions and requests will be triaged according to need; everyone who uses this email will receive a response. The goal is to streamline the request and workflow process to make it easier to access departmental services and resources.

Please continue to call Security at ext. 73300 for urgent requests and transportation requests.

Patient Safety and Quality Educational Lunch & Learn
The Patient Safety & Quality Educational “Lunch and Learn” is a one-hour session held the second Monday of each month from 12:30 to 1:30 p.m. in OCC A. Attendees can expect a brief presentation and discussion of quality improvement education. There may also be a project presentation (proposed, in progress or completed) that incorporates the quality improvement process or tool used. This forum applies adult learning principles and often incorporates group activities to simulate how quality tools are used in project management and patient safety, and promotes discussion and suggestions for new project direction and review.

These lunch and learn sessions are approved for CME hours through Johns Hopkins CME. Physicians who attend these sessions will be awarded one CME hour for each session attended through August 31, 2018. These sessions may also qualify for MOC (Maintenance of Certification) credit if the attendee is involved in any of the current MOC Quality Improvement Projects. Continuing education credit for nursing is also submitted for each session.

The most recent presentation was on December 12. Dr. David Berman and Katie Namtu, Pharm.D., presented antimicrobial stewardship. The January topic is to be announced.

Good Catch Winners
Good Catch award winners are selected monthly by a front-line workgroup that reviews “near miss” reports. A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near. Submission of near miss reports helps us identify trends that occur and guides us in preventive solutions. A Good Catch is scored based on potential of harm and probability of the near miss event; individuals are awarded on their insight and critical thinking involved to help prevent the event from occurring. Congratulations to the following Good Catch Award winners:

July 2016 winners are:

Stephanie Carroll, R.N., 7 South, Hematology/Oncology
Bethany Gregoire, R.N., Clinical Manager Heart Center West
Kris Guthrie, R.N., Lactation Educator
Honorable Mention: Jeffrey Amendola, Chief Perfusionist

August 2016 winners are:

Katherine Glazer, R.N., NICU
Elizabeth Brunk, R.N., Pediatric Medicine
Jessica Williams, Pharmacy Tech, Formula Room
Honorable Mention: Barbara Hayes, PCT, 7 North Neurosurgery

September 2016 winners are:

Barbara Hayes, PCT, 7 North
Elisa Iles-Sabol, R.N., CVOR – Heart Center West
Andrea Shimko, R.N., CVICU – Heart Center East
Honorable Mention: Andrea Shimko, R.N., CVICU – Heart Center East

JHM Clinical Excellence Award Nominees
Congratulations to these members of the Patient Safety and Quality Division who were recognized as nominees/winners of the 2016 JHM Clinical Excellence Awards at JHACH:

Dr. Fauzia Shakeel, neonatologist, received the Armstrong Award for Excellence in Quality & Safety. This is awarded to the physician who partners with patients, families, colleagues and staff to optimize patient outcomes and eliminate preventable harm. Dr. Shakeel developed and improved safer ways to deliver nutrition to infants in the neonatal ICU (NICU). She led projects on early introduction of breast feeding, cue-based oral feeding, standardized nutrition orders and family education, resulting in fewer complications, better recovery, shorter hospital stays and overall improvements in quality of care and patient safety. She also mentors physicians and residents in quality improvement projects.

Julie Navarro, R.N., Blood Management Coordinator, was nominated for the Innovations in Clinical Care Award. This is awarded to the physician, nurse and/or care team demonstrating a visionary approach to problem solving and performance improvement. Julie was recognized as a nominee for her commitment to improving processes around pediatric blood management and transfusion safety measures. She also works closely with providers in discussing the need for transfusions and is the liaison for patients and parents when they have questions regarding a possible transfusion.

Read more about all of the 2016 winners and nominees at JHACH.

Security TIP
As we enter holiday season, please be extra careful with personal items and/or packages. To prevent possible theft, do not leave personal belongings such as bags, cell phones, wallets, etc. in open view. In addition, if you see any abandoned or suspicious gift-wrapped packages, please contact Security immediately at ext. 73300.