Success
Stories
Success
in the transformation of a healthcare organization’s
culture of safety and performance excellence can be
demonstrated from simple stories of everyday excellence
such as the ones below.
While
going about her daily duties of cleaning a patient
room, Janice, an Environmental Services Associate
observed a physician and nurse enter the room
and prepare to perform a minor procedure. She
knew the hospital’s rule about site verification
before a procedure, yet noticed that the team
was about to proceed without the verification.
Janice politely questioned the physician and
nurse, “Shouldn’t we verify the site before
the procedure?” The physician and nurse thanked
the Associate and verified the site. By being
aware of what was going on around her and being
willing to speak up, Janice helped ensure that
the procedure was performed on the correct site. |
Barbara,
a Transporter, went to get a patient for an
EEG. The nurse asked Barbara to wait while she
gave the patient her medication. The nurse addressed
the patient as “Mrs. Hamilton.” Yet the patient
she was transporting was a patient by the last
name of Anderson. The patient was not that alert
and did not correct the nurse. Barbara stopped
the nurse and asked, “Are you sure you have
the right medication for Mrs. Anderson?” The
nurse stopped, and said, “Oh, you are right
- this is for another patient.” Good thing Barbara
spoke up – it prevented a patient from receiving
the wrong medication. |
The
day we changed sanitizing chemicals at our pot
sink, Nelson displayed a Questioning Attitude
by asking if the new chemical was at the right
concentration. The old chemical, you see, made
the water a bright blue color, and the new chemical
barely changed the color of the water. We tested
the concentration and both agreed that the concentration
was correct. Thanks, Nelson, for helping keep
our patients, staff, and visitors safe. |
The story below was provided by a nurse recognizing
a co-worker for being a great “wingman”:
“Hi,
I am Robin and I work in the ICU. This morning,
we had several patients that were not doing
well and then we received a crashing patient
on top of it all. In my attempt to facilitate,
I started directing questions to a nurse removing
medications from pyxis...as we know, this is
a no-no. The nurse was clearly in the 'cone
of silence' and I violated the no-talking rule.
Fortunately, we have great wingmen around us
and Mike (another nurse) quickly reminded me
that I should not be talking with her (peer
coaching). I stepped back, thanked Mike for
the reminder and waited another 10 seconds for
the nurse to finish and then asked my question.
I caused the nurse at the Pyxis additional stress
which could have triggered an error ...all for
the desire to save what turned out to be 10
seconds. How crazy is that?! Many thanks to
Mike for being a GREAT wingman!” |
Everyday
success is not just a clinical phenomena as the following
story illustrates:
The
HVAC Shop received a phone call from a nursing
unit requesting a negative pressure smoke test
in a patient room to be used for a lung transplant
patient. A Facility Services team member answered
the call and repeated back the request. A coworker
overheard the repeat back. Based on his knowledge
of the indications for positive and negative
pressure rooms, he found the request for a negative
pressure room for a lung transplant patient
very unusual. He suspected that this patient
really needed a positive pressure room. The
HVAC Shop called the nursing unit to question
the request, and the nurse then took steps to
question the request. The patient's physician
and Infection Control agreed that the patient
needed to be placed in a positive pressure room.
Follow up education about the indications for
the use of positive and negative pressure rooms
was conducted on the nursing unit. Clear communications,
questioning attitudes and never leaving your
wingman were at work in the Safety Success Story.
"The process worked, and we kept a patient
safe," Bart (the coworker) stated.
|
Questioning
clinical actions or decisions isn’t reserved for registered
nurses as the following two stories illustrate:
| A
unit secretary reviewed orders for two different
types of insulin for a patient. She noticed
that the two doses for the insulin - NPH insulin
ordered at 12 units and regular insulin ordered
at 32 units - were reversed. They weren’t written
in the way she was used to seeing from a particular
physician. The physician also had written the
order only the numeric doses and without any
dosage instructions. She contacted the physician
and asked clarifying questions that resulted
in a corrected order. The unit secretary had
paid attention to detail, had a questioning
attitude and was a wingman to this physician.
The physician was very grateful for this help
and shared the story with the secretary’s manager.
A
nursing assistant picked up a unit of blood
from the Blood Bank for a sickle cell patient.
She noticed that the unit of blood did not have
a specific label that she was used to seeing
on units of blood for sickle cell patients.
She asked the Blood Bank Technician about the
missing label. The Technician looked at the
patient profile, realized that the patient indeed
was a sickle cell patient. The mistake was discovered
and corrected, thanks to her attention to detail
and questioning attitude. |
Success can also be demonstrated by improved outcomes
in patient care. Two articles that illustrate the
success that Sentara Healthcare has achieved are below.
Yates,
GR, et al. “Sentara Norfolk General Hospital:
Accelerating Improvement by Focusing on Building
a Culture of Safety.” Joint Commission Journal
on Quality and Patient Safety. (30)10, October
2004, pp. 534 - 542.
Yates,
GR, et al. “Building and Sustaining a Systemwide
Culture of Safety” Joint Commission Journal
on Quality and Patient Safety. (31)12, December
2005, pp. 684-689.
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