At Brigham and Women’s Faulkner Hospital, delivering safe, high-quality care is at the center of all we do for our patients and their families. For staff members who exhibit exceptional care in regards to patient safety, the hospital recognizes them with a Patient Safety Award. The Pharmacy’s Bethany Bersani, PharmD, was recently honored with a Patient Safety Award.
Bersani was recognized for her attention to detail and good detective skills when she discovered a discrepancy in a patient’s medical record. The incident began when she noticed the patient’s home medication list from the Emergency Department note and his home medication from his History and Physical (H&P) note did not match. Bersani noticed there was an order for 150mg of Sertraline, an antidepressant, listed as daily in his H&P, but she could not find a depression diagnosis or any record of the patient receiving this medication in the past. Bersani had been alerted due to concern about the dose of medication and how it could contribute to falls in the elderly. After notifying the care team of a possible medication discrepancy, she also called the patient’s nursing home listed in his H&P. At that point, she discovered the patient was not a resident of that nursing home. Bersani alerted the resident who spoke with the patient’s healthcare proxy. It turned out the medication list documented in the patient’s H&P was not his medication list. The healthcare proxy also confirmed that the patient did not live at the nursing home listed in the chart. The resident immediately discontinued the medications that had been ordered and got the correct patient medication list from his actual nursing home. Bersani then verified the patient’s new medication orders. It was her critical thinking and diligence in checking the medications against the diagnosis list that helped her catch the error and prevent harm to the patient.
Director of Patient Safety, Quality, Infection Control and Accreditation Christi Barney, MSN, RN, CS, surprised Bersani with her award in the Pharmacy in front of all of her co-workers. “It was actually someone else’s medical record that went into the system under this patient’s name,” Barney said. “You did all the detective work and figured it out and closed the issue.”
Bersani was touched to be recognized with her Patient Safety Award. “It is truly an honor to be recognized. Medications play an important role in many patients’ overall healthcare and it is critical to me that each patient is on appropriate and correct medication regimens,” she said of the honor. “This recognition encourages me to continue to be diligent while reviewing patient medications.”
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