2025 Imagine - P150 - Reducing Harm, Increasing Efficiency: Transforming the Sentinel Fall RCA Process - On Demand

 In 2023, the Hospital of the University of Pennsylvania saw a 24% increase in patient falls with major injuries, prompting an overhaul of its root cause analysis (RCA) process. A centralized, electronic, comprehensive causal analysis tool was developed, leading to a faster, more effective process for evaluating and preventing falls with major injury. RCA completion times reduced by 72% and the rate of falls with major injury reduced by 29%. This session will explore the process improvements and their sustained impact on patient safety and efficiency. 

Target Audience

  • Dietitians
  • Nurses
  • Pharmacists
  • Pharmacy Technicians
  • Physicians
  • Physician Associates
  • Healthcare Quality Professionals
  • Other Healthcare Professionals

Learning Objectives

 
Upon completing this enduring material, learners should be able to:
  • Describe how to simplify sentinel fall RCAs into a structured electronic process that reduces RCA completion time and accelerates process improvement. 
  • Identify strategies for leveraging close to real-time data analysis to drive hospitalwide improvements in fall prevention and quality management. 
Course summary
Available credit: 
  • 0.50 AAPA CME
    Vizient Inc. has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria.
  • 0.50 ACPE Pharmacist
  • 0.50 ACPE Pharmacy Technician
  • 0.50 AMA PRA Category 1 Credit™
  • 0.50 ANCC
  • 0.50 CDR
  • 0.50 CPHQ – Certified Professional Healthcare Quality
  • 0.50 General CE - Attendance
Course opens: 
10/07/2025
Course expires: 
10/06/2026
Statement of Content Validity
 
Vizient, Inc. educational activities are intended to assist healthcare teams advance their professional responsibilities in accordance with the definition of continuing education. It is the policy of Vizient, Inc. to review and ensure that all content and recommendations for patient care within accredited CE is evidenced-based, based on current science and clinical reasoning while ensuring the content is fair and balanced. All recommendations must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation. Vizient, Inc. does not permit accredited continuing education if it advocates for unscientific approaches to diagnosis or therapy, or if the education promotes recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.
 
FDA Off-Label Use
 
Faculty presenters are also expected to disclose any discussion of (1) off-label or investigational uses of FDA approved commercial products or devices or (2) products or devices not yet approved in the United States.
 
 
Disclaimer
 
The education provided through this activity is for continuing education purposes only. The views and opinions expressed in this activity are those of the faculty/presenters and do not necessarily reflect the views of Vizient, Inc.
 
Faculty & Planners
 
Faculty
 

Leticia "Tish" Pendleton, MSN, RN, CBC, CSSGB, Manager of Nursing Quality/Performance Improvement, Penn Medicine, Philadelphia, Pa. 

Meghan Maini, MSN, RN, CSSBB, Clinical Director of Quality, Penn Medicine, Philadelphia, Pa. 

Steven Gudowski, RRT, ASQ CSSGB, Director of Patient Safety, Penn Medicine, Philadelphia, Pa. 

Justin Walters, MSN, RN, CCRN, Patient Safety Manager, Penn Medicine, Philadelphia, Pa. 
 
 
Planning Committee
 
Juli Hermanson, MPH, RDN, CPHQ (Course Director)
Senior Director 
Member Education 
Vizient, Inc. 
 
Kathy Christensen, BS 
VP, Operations 
Member Networks 
Vizient, Inc. 
 
Cheryl Jachna, BS 
Lead Education Programs Manager 
Vizient, Inc. 
 
Marilu Kelly, MSN, RN, NPD-BC, CHCP 
Director 
Continuing Education 
Vizient, Inc. 
 
David Levine, MD 
Chief Medical Officer 
Vizient, Inc. 
 
Lisa McClain, BS 
Networks Manager 
Member Education 
Vizient, Inc. 
 
Mike Oinonen, PharmD, MPH 
Vice President 
Pharmacy Networks 
Vizient, Inc. 
 
Disclosure
 
As an accredited provider of continuing education, Vizient, Inc. is dedicated to ensuring this activity presents learners with only accurate, balanced, scientifically justified recommendations, and is free from promotion, marketing, and commercial bias. In accordance with The Standards for Integrity and Independence in Accredited Continuing Education, all planners, faculty, and others in control of the educational content have disclosed the absence or existence of all financial relationships (of any dollar amount) with ineligible companies within the past 24 months.
 
Ineligible companies – those companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
 
It is Vizient’s policy that owners and employees of ineligible companies, and any individuals who refuse to disclose the absence or existence of financial relationships with any ineligible companies are disqualified from participating as planners or faculty.
 
Disclosure Statements
 
Absence of Relevant Financial Relationships
 
None of the planners, faculty, or others in a position to control content for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant financial relationships listed for these individual(s) have been mitigated.​
​

Joint Accreditation Statement

In support of improving patient care, Vizient, Inc. is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

 

Designation Statement(s)
 
Interprofessional Continuing Education (IPCE)
This activity was planned by, and for, the healthcare team, and learners will receive 0.50 Interprofessional Continuing Education (IPCE) credits for learning and change.
 
 
 
Registered Dietitians/Dietetic Technicians (CDR)
 

The Commission on Dietetic Registration (CDR) accepts nutrition-and-dietetics-related continuing education credits from Jointly Accredited Providers. After completing this activity, CDR-credentialed practitioners may claim CPEUS under Activity Type 102; 1 contact hour (60 minutes) = 1 CPEU. 

 
Nurses (CNE)
 
This activity is designated for 0.50 ANCC contact hours.
 
Pharmacists (CPE)
 
Vizient, Inc. designates this enduring material for a maximum of 0.50 contact hours for Pharmacists.
 
Universal Activity Number: JA0006103-0000-25-255-H04-P
 
Pharmacy Technicians (CPE)
 
Vizient, Inc. designates this enduring material for a maximum of 0.50 contact hours for Pharmacy Technicians.
 
Universal Activity Number: JA0006103-0000-25-255-H04-T
 
Physicians (CME)
 
Vizient, Inc. designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
 
Physician Associates (AAPA)
 
Vizient, Inc. has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.50 AAPA Category 1 CME credits. Approval is valid until October 6, 2026. PAs should only claim credit commensurate with the extent of their participation.
 
Healthcare Quality Professionals (CPHQ)
 
This activity is approved by NAHQ® for 0.50 CPHQ CE credits.
 
Other Healthcare Professionals (General CE Credit)
 
Vizient, Inc. will award all other healthcare professionals who successfully complete the activity a Certificate of Participation.  Various state license boards and credentialing bodies accept certificates of participation from accredited CE activities to meet CE requirements for license renewals and re-certification. It is the responsibility of the participant to contact their state licensing board and/or certifying body for verification on credit eligibility reciprocity.

 

Available Credit

  • 0.50 AAPA CME
    Vizient Inc. has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria.
  • 0.50 ACPE Pharmacist
  • 0.50 ACPE Pharmacy Technician
  • 0.50 AMA PRA Category 1 Credit™
  • 0.50 ANCC
  • 0.50 CDR
  • 0.50 CPHQ – Certified Professional Healthcare Quality
  • 0.50 General CE - Attendance
Please login or register to take this course.

 

Select the “Obtain Credit” button to access the session evaluation and to claim CE Credit.

 

Please Note: 

 

  • If the "Register/Take Course" tab is displayed instead of the "Obtain Credit" tab, you must first login to proceed with the credit claim process.
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  • Please click here to enter the code you received at the end of the session to verify your attendance if you have not already done so: https://continuingeducation.vizientinc.com/code

 

 

Required Hardware/software

 

The Vizient CE Learner Portal is compatible with most modern web browsers (such as Firefox, Google Chrome, Microsoft Edge, Apple Safari) and can also be accessed with mobile devices.