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.
The story 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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