Nursing Leadership and Education, Physicians, EPIC Team, Patient Safety, and Library Staff
UPMC Carlisle and Central Pennsylvania Hospitals

In response to an adverse event related to continuous urinary bladder irrigation, a multidisciplinary team at UPMC Central Pennsylvania Hospitals—including nursing leadership, nursing education, urology physicians, ED physicians, hospitalists, EPIC Team, Patient Safety Department, and library representatives—created and implemented a continuous urinary bladder irrigation order set and nursing education. These were implemented at all hospitals in the region, and the event was discussed in forums and shared in a patient safety newsletter to show how transparency and collaboration can result in system improvement for patient safety.

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