Prompt action by employee spurs safety change

A Backus Hospital staff member recently recognized a potential patient safety issue and was the driving force behind a hospital systems change that will no doubt benefit patients.

The Critical Care Unit staff member, who asked not to be identified, noticed a potentially serious patient safety issue related to Medication Reconciliation forms and post operative procedures.

Here is what transpired:
? A patient returned from surgery with an outdated medication reconciliation form.
? The form was completed renewing medications that were not current.
? The staff member caught the problem before medications were administered, and alerted her clinical director, Debra Furtado, RN.

Ms. Furtado said the staff members actions have resulted in a change that will benefit patient safety. She said prior to the incident, when patients went from surgery to an inpatient unit, it was expected that the inpatient unit coordinator would print up and send the most current medication reconciliation form with the patient’s chart. That form was to be utilized by the surgeon during the post operative ordering of medications.

“This is an exceptionally unstable time for patients returning to the CCU from surgery with medications being of the utmost importance,” Ms. Furtado said. “If the order form in the chart was not printed up and an old, outdated version was left sitting in the chart for the surgeon to review, potential danger was just a step away.”

Under the new protocol, which is the direct result of the staff member’s actions and her recommendations, PACU simply prints the most current form in that department and makes it available to the surgeon when orders are written. PACU Clinical Director Shelbye Maynard, RN, gladly agreed with the plan and implemented the change in her department.

The staff member also recommended that Nursing Informatics be alerted to the situation, which Ms. Furtado did.

Karen Long, RN, Vice President and Chief Nursing Officer, praised the staff member for her due diligence and eagerness to alert the appropriate parties.

“This is a perfect example of the benefits of checking and double checking every step in the process of administering medication to our patients, and taking action to address a patient safety issue,” Ms. Long said. “This staff member did exactly the right thing for our patients. Patient care has been improved due to her attention to detail and willingness to communicate.”

Peter Shea, MD, Medical Director, encouraged all Backus staff to pay attention to patient safety issues in their department, and if issues are identified, think about how other departments might be involved to reduce the chances of the problem popping up again.

“In order to improve patient safety, we must push for systems-wide change,” Dr. Shea said. “That can’t happen if we aren’t thinking outside the box, and communicating with our colleagues in other departments. In most cases, more than one department is involved and need to be brought into the loop.”

Mary Bylone, RN, Assistant Vice President, Patient Care Services, said this is the perfect example of identifying and correcting a systems issue that put good people at risk for failure.

Ms. Bylone added that medication safety and communication among caregivers are important components of the Joint Commission on Accreditation of Healthcare Organization’s Patient Safety Goals. Anyone with questions about the upcoming JCAHO visit, or suggestions to improve patient safety at Backus, should call Ms. Bylone, who is the hospital’s Patient Safety Officer, at ext. 2771, or Joe Hughes, Director of Quality Improvement, at ext. 2345.