The Patient Safety Authority (PSA) established the I AM Patient Safety Achievement Awards1 to recognize that everyone in healthcare has a role in patient safety: admission registrars, nurses, physicians, pharmacists, environmental staff, and more. The annual IAPS contest is an opportunity for healthcare staff to celebrate and share the inspiring stories of peers who go above and beyond to ensure safe care for their patients.
This year, PSA introduced several new award categories to highlight champions for their commitment to safety, solutions to address healthcare disparity, improving the medication administration process, and educating and engaging patients as partners in their own care. Although only one person or team can win the award in each category, every nominee deserves congratulations for their extraordinary efforts, accomplishments, and contributions to patient safety. Many of their successes will be published on the PSA’s website as examples of how event reporting catalyzes change that improves care within a facility, a health system, or even nationwide.2
The 2025 IAPS awards were judged by patient safety advocates; government, university, and patient representatives; and healthcare executives, who carefully evaluated 147 nominations from 50 healthcare facilities for innovation, impact, sustainability, and scalability. In addition to the nine juried awards, PSA Executive Director Regina Hoffman, MBA, RN, selected a Choice Award winner for special recognition.
Executive Director’s Choice Award
Fernanda Basso Alcoforado
Main Line Health
While doing her 15-minute safety rounds, mental health technician Fernanda Basso Alcoforado observed a patient on the Inpatient Psychiatric Unit for depression and suicidal ideation who appeared superficial and preoccupied. The patient denied any need for help, but on the next set of rounding, Alcoforado broke from her routine and returned early to the patient’s room. The patient was in the bathroom, denied any issues, and said they would be out soon. Out of continued concern for the patient, Alcoforado entered the bathroom—to find the patient with a shirt tied around their neck. Alcoforado hit their alarm button and untied the shirt. She then stayed with the patient and took them to the nurse’s station for further assistance.
Safety Story Award
Women and Children Team and Pulmonary Services Team
WellSpan York Hospital
An unexpected issue occurred during a scheduled medical gas shutdown, impacting a critical care unit. The clinical coordinator and charge nurse of the affected unit immediately began communicating with other charge nurses, respiratory therapists, and the house supervisor. They acted swiftly and effectively, ensuring the safety and well-being of the patients.
The charge nurse contacted administration at home to bring awareness to the situation, and nurse leadership promptly came in to assist. The house supervisor was kept informed of the critical nature of the issue. Teams rallied to provide necessary resources, and an additional unit charge nurse mobilized the team to be ready for any potential evacuations.
The pulmonary team also went above and beyond, ensuring that all ventilators had the necessary air to function. Due to the resiliency and teamwork of all involved, all patients received appropriate care throughout the event and were able to remain on the unit until the medical gas was restored.
Following the event, efforts have been ongoing to identify opportunities for improvement, including evaluating the unit’s evacuation plan and enhancing communication processes.
Individual Impact Award
Andrea Colfer
Children’s Hospital of Philadelphia
Despite working in patient safety at Children’s Hospital of Philadelphia (CHOP) for many years, Andrea Colfer continues to propose innovative ways for patient safety staff to best approach their work. Last year alone, she organized and facilitated working sessions and presented to leadership a total refresh to CHOP’s major event analysis that will include a huge culture shift to allow for better reflection on why an error may have occurred and how the team can best add system solutions. This refresh moves away from focusing on deviations, allowing review teams to engage in open dialogue and increase psychological safety.
Colfer is constantly pushing CHOP staff to think through their processes to better themselves for both the employees they interact with and the patients their teams care for. She does this in addition to her daily work because she is passionate about patient safety. For example, Colfer created a patient safety book club that has cultivated amazing conversation amongst the patient safety team members about their goals and how to reflect on their purpose and mission.
In true passion for promoting patient safety, she is also creating a curriculum for a patient safety certificate program. Colfer is consistently adding the voice of the patient or family as the team considers any harm, and she gives every event review careful thought and attention.
Transparency and Safety in Healthcare Award
The Nurses at the Crozer Endoscopy Center at Brinton Lake
Crozer Health
The nurses at the Crozer Endoscopy Center at Brinton Lake implemented an action plan to complete risk event reports for multiple events that were not captured previously due to lack of knowledge, fear of punishment, or other reasons. Their second goal was to have more people reporting these events.
The nursing staff received education, and a list of possible events was posted at every nurse’s station. At the end of the day, checks were completed to see whether any events were overlooked so as not to miss reporting one. The results were successful. The number of reported event types went from two to five, and reported events per month went from one to 16 (some being procedure not completed due to poor preps). The number of nurses reporting went from one to eight (there are only nine nurses in the department). A list of the reporting nurses for that month is posted on the information board as positive reinforcement. The nurses feel safe in being transparent in event reporting now. Next, the facility will take this data to see how to improve the patient prep process.
Patient Communication Award
Lisa Kolodziejski
UPMC St. Margaret
Over the past four years, Lisa Kolodziejski has gone above and beyond to transform total joint replacement and geriatric fracture programs at UPMC St. Margaret through innovation and patient-centeredness. She has significantly impacted patient care by reducing harm and improving outcomes.
She is not just the patient’s navigator on their total joint replacement journey—she is their coach, quarterback, and cheerleader. She conducts a total joint class, first meeting all patients prior to their surgery. Initially, these classes were held only during the day and in person. To better meet patients’ needs, she increased participation by offering evening and online classes, allowing more patients to participate despite daytime responsibilities or long distances from the hospital. Participation increased significantly with these additional options.
Kolodziejski expanded the class content by including examples of high-protein items that promote wound healing. A dietician now participates in the class, explaining the importance of increased protein consumption pre- and post-surgery. The class also features a physical therapist and an occupational therapist who demonstrate preoperative and postoperative exercises and the use of equipment and aids to assist in recovery. Patients and caregivers consistently provide positive feedback on the importance of the class to their recovery; the class helps reduce patient harm by preventing surgical site infections, venous thromboembolism, and mechanical failure of the joint, and by decreasing length of stay and readmissions.
Kolodziejski also visits overnight patients the day after surgery, encouraging them and their caregivers towards discharge and reinforcing the education provided during the class. All patients continue to receive coaching after discharge through follow-up phone calls to address any concerns or clarify instructions. She drives the success of the total joint program through her collaboration with surgeons, pharmacy, rehab services, nutritional services, nursing, and surgical teams.
Her dedication extends to the geriatric fracture program, focusing on improving patient care by consistently meeting door-to-operating-room times under 24 hours and developing patient care pathways to improve outcomes by reducing length of stay and readmissions. Recently, there has been an increase in patients being discharged to home. She also volunteers at health fairs, where she provided 95 bone density screenings and educated 551 community members throughout 2024.
Commitment to Safety Award
Penn Medicine Rehabilitation
Hospital of the University of Pennsylvania and GSPP Rehabilitation
When patient elopements at Penn Medicine Rehabilitation increased in fiscal year 2023, an interdisciplinary team reviewed the data to identify opportunities to reduce these events.
Elopements are high-risk events, as patients can incur harm or injury during them. Rehab defines elopement events as when patients leave the hospital premises outside of therapeutic committee activities. Upon further review of the events in FY23, it was discovered that they occurred more frequently but were not reported in the event reporting system.
Upon diving deeper into the events, the team noted that most elopements occurred between 6 p.m. and 9 p.m., and the most reported reason was to purchase food or snacks at nearby food retail establishments. Most often, staff were not aware the patient had left the floor. Penn Rehab did have a “patient outside” process that required an order from the provider, the patient staying on the property in the patient-designated outside area, the patient being accompanied by a family member or other visitor, signing out before they leave the unit, and returning to the unit within 30 minutes of leaving. The team discovered that most patients who left reported not being aware of the outside process.
The hospital implemented an action plan which included
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Closing the unit doors during peak elopement times
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Adding vending machines to the rehab unit in space accessible to patients
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Creating signs for the outside of the building that identify patient-designated areas with pictures and include instructions that patients are not to leave the premises and must return to the unit within 30 minutes
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Creating patient and staff education about the off-unit process and reviewing the process with patients upon admission
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Adding yellow tape to all hospital wheelchairs so inpatients will stand out if they are off the unit
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Educating all staff, including security, that if a patient is off the unit and alone, they contact the unit and bring the patient back to the unit.
The hospital is currently trialing Apple AirTags on hospital wheelchairs so if a patient does elope, they can be located quickly.
The initiative reduced inpatient elopement events from nine in FY23 to six in FY24. Of note, the team feels there were more events in FY23 that were just underreported. They continue to review each elopement event to learn from it and are working on additional interventions to continue reducing these events.
Improving Diagnosis Award
Penn Medicine Enterprise High Sensitivity Troponin Implementation Team
Penn Medicine
Per the 2021 American Heart Association and American College of Cardiology guidelines, high-sensitivity cardiac troponin assays (hs-cTn) are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury in the evaluation and diagnosis of chest pain or anginal equivalents. Transitioning from conventional cardiac troponin to hs-cTn also allows for earlier rule out while reducing rates of missed myocardial infarction. However, troponin may also be elevated in conditions such as cancer, diabetes, and end-stage renal disease. In this setting, there are concerns that implementation of hs-cTn can include risks of diagnostic errors, inappropriate admissions, rise in cardiology consultations and unnecessary imaging, and delayed discharges from the emergency department (ED).
To provide accurate result interpretation and diagnosis, the Penn Medicine Enterprise High Sensitivity Troponin Implementation Team developed hs-cTn chest pain algorithms through multidisciplinary teams across five hospitals. This pathway was developed for various clinical settings, including the ED and outpatient and inpatient populations. The ED algorithm was particularly complex. Instead of relying on a single value and a reference range, proper use requires evaluation within the clinical context and interpretation of temporal changes (deltas) at set intervals such as baseline, at one and/or three hours relative to presentation. To further support this paradigm shift, both in workflow and interpretation, Penn Medicine developed innovative, patient-centered clinical decision support tools to display real-time status updates, including reminders for lab collection for nursing staff and automatic interpretation guidance for acute coronary syndrome in the electronic health record (EHR).
The team formed an enterprise, interdisciplinary governance group of 89 participants, designed research-based algorithms embedded in the EHR, and developed a clinical reference site. Additionally, they coordinated the launch with laboratory teams, educated more than 8,000 caregivers, and implemented an electronic dashboard for continuous monitoring. Since initiation, Penn Medicine has also scaled its tools outside of the enterprise’s five hospitals to an organization in Texas.
The initiative launched successfully in June 2022, achieving a smooth transition to high-sensitivity troponin without diagnostic errors, inappropriate admissions, or increased cardiology consultations. Diagnoses of non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) improved for chest pain patients, who also benefited from detailed test results via the patient portal and providers. Benefits realized include:
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Patients with chest pain or shortness of breath saw a 13% increase in ED discharge dispositions and a 17% decrease in observation dispositions
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Patients with chest pain had a 26% decrease in ED observation dispositions
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Reduced ED length of stay by 71 minutes for admitted cardiac patients and 24 minutes for discharged patients
The initiative generated more than $3.9 million in savings within 10 months by reducing length of stay, enhancing patient throughput, and increasing ED capacity. This project aligned with Penn Medicine’s institutional goals of quality, patient safety, continuity of care, high reliability, and innovation, and achieved a smooth implementation and sustained successful outcomes—providing significant safety benefits for patients, inclusive of quicker, more accurate diagnosis, as well as ED utilization.
Healthcare Disparity Award
Sarah Prylinski
UPMC Hamot
Sarah Prylinski at UPMC Hamot exemplifies what it means to be a changemaker in reducing healthcare disparities and improving patient outcomes. As the clinical program manager at a community development corporation, she mentors and directs the work of three community health workers, comprising a team focused on addressing the social determinants of health in the community.
Perhaps even more impressive is how Prylinski has served as the driving force behind a groundbreaking street medicine program, leading its development and implementation. The program’s purpose is to address an urgent and challenging gap in healthcare access in the community: the needs of individuals experiencing homelessness.
In fall 2024, she helped secure more than $20,000 in grant funding to launch the street medicine program. From conceptualization to execution, she has been the backbone of the initiative. Her leadership and hands-on efforts directly contribute to reducing harm and improving patient care for the most vulnerable populations. As a result, she is hailed as an angel among the unhoused.
Prylinski’s work begins where traditional healthcare often ends: inside shelters and on the streets. She meets patients where they are, providing nursing care in settings that are accessible and familiar to them. Her efforts include helping individuals manage chronic conditions by educating them about their medications, organizing and refilling pillboxes, administering vaccines, and caring for wounds and infections. Her ability to break down barriers to care is further demonstrated by her commitment to scheduling and attending medical appointments with patients, ensuring they receive the follow-up care they need.
Her approach is holistic, innovative, and deeply empathetic. She recognizes that healthcare disparity is rooted in systemic issues and actively works to educate both patients and providers about the challenges faced by those experiencing homelessness. In doing so, her efforts have provided actionable and invaluable insights for the team regarding how to best close those gaps.
The street medicine program not only delivers essential medical services but also fosters trust and dignity among a population that often faces stigmatization and neglect. As a result, Prylinski has become a lifeline for those who might otherwise resist trusting a medical professional and fall through the cracks of the healthcare system.
Through her pioneering street medicine program and daily outreach efforts, Prylinski has demonstrated that one nurse’s vision and perseverance can drive meaningful change. She seamlessly combines the roles of caregiver, advocate, leader, and educator, making her a unique part of the healthcare landscape.
Ambulatory Care
UPMC St. Margaret Harmar Outpatient Center
UPMC St. Margaret
The staff at UPMC St. Margaret Harmar Outpatient Center has made outstanding contributions to patient safety and shown commitment to excellence in ambulatory care. One of their key initiatives involved improving preoperative and postoperative calls to manage patient nausea and vomiting effectively. They discuss patient history during preoperative calls, administer medications in the perioperative setting, review discharge instructions thoroughly, and emphasize follow-up phone calls for postoperative recovery.
The team implemented a dedicated cellphone for patient communication, which has improved preoperative and postoperative contact rates. Through this initiative, the clinician texts the patients prior to calling, allowing the patient to recognize the number so that they answer the call.
They have also prioritized pain reassessment management. Active collaboration with anesthesia providers ensures that pain medication aligns with patient pain scores, providing tailored pain management. Addressing issues within the prebuilt power plan has led to overall improvements in documentation and compliance processes.
In pediatric patient care, staff have successfully increased to 100 pediatric orthopedic cases with no admissions, transfers, or infections reported for age groups 0–17.
The team continues to work on improving outreach and education, with new discharge instructions introduced earlier in the year which have received positive feedback. Operational improvements are also underway, including the installation of new tracking boards and the development of a form for support persons.
Their dedication to patient safety and continuous improvement is evident through their innovative initiatives and collaborative efforts. Their focus on effective pain management, regulatory compliance, and enhanced communication has significantly advanced surgical safety and patient care.
Medication Safety Award
Christine Zdaniewski
UPMC Hamot
Christine Zdaniewski serves as the lead pharmacist for decentralized patient care services, a critical care clinical pharmacy specialist, and the postgraduate year 1 (PGY-1) pharmacy residency program director at UPMC Hamot. In 2024, she reported 16 medication-related events, of which 10 were good catches or pharmacy interventions that had significant patient impact. Through chart reviews and rounding on her units, she detected and prevented multiple severe drug-drug interactions, optimized drug therapy with appropriate dosing, and prevented significant harm by escalating inappropriate drug therapies.
The most important aspects of her work are her dedication to education and her commitment to driving positive change. She does not just find and report issues but follows up with the entire team caring for the patient and provides education to prevent future errors. She educates the care team, unit directors, nurses, providers, and the pharmacy team as needed. She partners with other departments to ensure clear and concise communication and escalates issues to local committees, as well as to system-level service line leaders to ensure appropriate interventions are implemented across the system. She ensures that the pharmacy residency program attracts the most qualified candidates, provides the best training, and instills in them a commitment to patient safety and pharmacy involvement in the care team.
One example of Zdaniewski’s contributions is her reporting of a medication event involving low-dose ketamine administration for pain, a therapy that was new to the facility at the time. She not only reported the event but also partnered with the ordering physician and his team to develop educational materials for pharmacy and nursing. She ensured that the associated policies were updated and continues to communicate with the morning safety huddles and pharmacy team to ensure medication availability for patients scheduled for procedures requiring this therapy.
Another example is her discovery of multiple instances of orders approved with a severe drug-drug interaction between carbapenems and valproic acid. She intervened to prevent additional administration to the patients, and she prepared and provided education to the pharmacy team to help prevent future orders from being approved. She provided the background information, explained the “why” behind the concern, outlined the potential risks, and explained the appropriate procedures to prevent the error in the future.
Runners–Up
Ambulatory Care
Jazmin Mendoza, Farm Journal Building, Pennsylvania Hospital
Julie Triplett, AHN Bethel Park Surgery Center
Commitment to Safety
Jennifer Higgins, WellSpan Good Samaritan Hospital
Perioperative Services Leadership and Education Team, Pennsylvania Hospital
Healthcare Disparity
Michele Ferguson-Davis, Guljinder Chera, Salman Qureshi, Olubunmi Olarewaju, and Patricia Nichols, Jefferson Torresdale Hospital
Community Health Needs Assessment Committee: Terri Pellegrino, LaQuicha Anderson, Valerie Bicker, Diane Corr, Donna Tassos, Lia Gallagher, Kristen Guinther, Daniel Hedayati, Michele Hilty, Carole Hoy, Michelle Ikoma, Bill Jordan, Kevin MacDonald, Megan McGrady, Jennifer McMahon, James Mercuri, Lacey Murray, Erin O’Connor, Michele Orsini, Alex Pantoja, Sanketh Proddutur, Courtney Riedel, Bethany Rose, Justin Rose, Ryan Witt, Chelsey Wojcik, Linda Yelen, and Faith Colen, UPMC St. Margaret
Improving Diagnosis
Jefferson Health Northeast and Bensalem Rescue Squad Mobile Stroke Unit, Jefferson Torresdale Hospital
Saundra Jones, UPMC St. Margaret
Individual Impact
Gustaaf De Ridder and Physician Clinical Pathology Laboratory Medicine PhDs, Geisinger Medical Center
Elizabeth King, Penn State Health Milton S. Hershey Medical Center
Medication Safety
Maryann Scholl, UPMC Hamot
Infusion Center Pharmacy Nursing Workgroup, Pennsylvania Hospital
Patient Communication
Kirkland Village Healthcare Center Clinical Team, Kirkland Village
Melissa Smock, UPMC Hamot
Safety Story
Robert Bayer and John Paoletti, Jefferson Torresdale
Maura Kessler, Lehigh Valley Hospital–Pocono
Transparency and Safety in Healthcare
Rebecca Geddes and the PAH Patient Safety Team, Pennsylvania Hospital
Lisa Esolen, Kelly Goff, Matthew Jesso, and the System Quality Department, The Guthrie Clinic
Thank you to this year’s judges:
Jackie Afranie, MPH, Betsy Lehman Center for Patient Safety
Mike Bruno, MD, Penn State Health
Sophie Campbell, MSN, RN, PADONA/LTCN
Daniel Feinberg, MD, Pennsylvania Hospital
Diane Frndak, PhD, MBA, Robert Morris University
Regina Hoffman, MBA, RN, Patient Safety Authority
Stephen Lawless, MD, Nemours Children’s Health
Ariana Longley, MPH, Patient Safety Movement Foundation
Dwight McKay, Patient representative
Heidi McMullan, MSN, RN-BC, WellSpan Philhaven
Marty Raniowski, MPP, PAMED
Rob Shipp, PhD, RN, HAP
Stanton Smullens, MD, Retired
Eric Weitz, Esq., The Weitz Firm
About the Author
Eugene Myers (eugemyers@pa.gov) is the associate editor of Engagement and Publications for the Patient Safety Authority. He previously served as editor-in-chief of Communications, Office of Institutional Advancement, at Thomas Jefferson University and Jefferson Health. He earned his bachelor’s degree from Columbia University, is a graduate of the Clarion West Writers Workshop, and is a New York Times bestselling and award-winning author of books for children and young adults.
Disclosure
The author declares that they have no relevant or material financial interests.