Great Catch winners

Christian Rohach, PharmD, was searching for normal saline for teaching purposes and noticed two opened multi-dose vials of labetalol 100mg/20mL mixed in with the 10 mL vials of normal saline in a nursing supply cart. Since normal saline vials are used to reconstitute medications frequently in this care area, he recognized a high risk for patient harm if the wrong vial was inadvertently used.  He promptly discarded the labetalol vials and escalated his concern to the charge nurse. Thanks to Rohach’s use of the CHAMP behaviors of Attention to Detail and Mentor Each other – 200% Accountability, he identified, mitigated and escalated an unsafe situation.

Note: This Great Catch was awarded before the conservation protocols put in place to address the severe IV fluid shortage in the U.S.

Eugene Glines, surgical technician, Operating Room, was recognized for using CHAMP behaviors during a total hip replacement. When the surgeon handed Glines a drill from the surgical field, Glines noticed that the drill-bit looked slightly different. Suspicious that a portion of the drill bit had broken off, Glines alerted the surgeon and the surgical first assistant. Glines stopped the line until the drill bit piece was found so that the procedure could continue. Glines’ questioning attitude saved the patient from a possible post-operative complication.

Michael Gualano, pharmacist, and Sophia Yanes, pharmacy technician, were recognized for using CHAMP behaviors in the care of a patient receiving an opioid via a patient-controlled analgesia pump (PCA). Several hours after starting the PCA, the medication was intentionally changed to a stronger concentration. Later that night, nursing requested a new infusion cassette. Recognizing that the new cassette with the stronger concentration should have lasted longer, Yanes consulted with Gualano, who identified a potential medication error. Gualano and Yanes collaborated with the nursing team to troubleshoot and found the medication concentration pump setting was incorrect. Gualano and Yanes responded to their internal smoke detectors, spoke up for safety and stopped the line to identify a potentially life-threatening medication safety event.