Charlese Carr, unit associate, Saint Raphael Campus PACU, was recognized for attention to detail, speaking up for safety and escalation of concerns. While checking a patient into the unit, she noticed they appeared unwell and questioned their spouse about the patient’s normal baseline. Suspecting the patient was having a stroke, Carr alerted the PACU staff, who expedited the patient into the unit for evaluation and called a stroke code.
Amber Ryan, RN, Medicine 7-5, was recognized for practicing a questioning attitude, 200% accountability and speaking up for safety. Ryan’s charge phone notified her of a critical heart rate alarm, which occurs when the patient’s primary nurse doesn’t respond to the alarm. Upon assessment, Ryan spotted a discrepancy in which patient’s alarm was sounding. She escalated her concerns and an investigation showed the heart rate monitor was not connecting correctly to the unit’s system.
Daisy Cruz, RN, Labor and Delivery, recently received Bridgeport Hospital’s Great Catch award. Cruz was caring for a pregnant patient scheduled for an injection she needed because of her blood type. Cruz was notified that the patient’s blood type was O positive, and she would not need the injection. Cruz questioned the results, demonstrating attention to detail and a questioning attitude, and checked the patient’s chart. She verified the patient’s blood type was O negative and escalated her concerns to the Blood Bank. Another type screen showed that the patient’s blood type was O negative and she should receive the injection. Thanks to Cruz’s use of CHAMP behaviors, the patient received the medication needed for safe future pregnancies.
Lisa Henderson, APRN, had a pediatric patient who was prescribed Augmentin and Zithromax for recurrent pneumonia. During a follow-up call with the mother, Henderson verified that the patient was taking the Augmentin, a white tablet, and the Zithromax, a red tablet. When the mother said she had pink instead of white tablets, Henderson called the pharmacy that dispensed the medications and learned that amoxicillin had been dispensed instead of Augmentin. She immediately instructed the mother to return to the pharmacy to obtain the correct medication and return the amoxicillin to avoid further confusion. Henderson practiced a questioning attitude, using the two-step validate and verify process. She validated when her “internal smoke detector” told her something wasn’t right and verified by checking with a trustworthy source – the pharmacy. Henderson’s use of CHAMP behaviors prevented a medication safety event.
While reviewing labor and delivery epidural carts, Tiffany Denepitiya, MD, noticed the absence of Intralipid, an IV medication used as a lifesaving measure in some situations. Dr. Denepitiya’s attention to detail and questioning attitude alerted the care team to a critical vulnerability. Anesthesia, Pharmacy and Labor and Delivery quickly collaborated to resolve the issue and ensure the medication is readily available, preventing patient harm. This Great Catch also illustrates the HRO principle, preoccupation with failure – a constant focus on identifying potential failures and collaborative problem solving among all employees. Thank you, Dr. Denepitiya and the healthcare team for speaking up for safety, fostering a culture of learning and engaging in continuous improvement.
