Josie King Foundation and the Johns Hopkins Hospital Department of Nursing Patient Safety Heroes
On Wednesday the Josie King Foundation and the Johns Hopkins Hospital Department of Nursing recognized nine nurses, one clinical technician and one support associate for their work in patient safety at Hopkins Hospital. These professionals were nominated by peers in their unit for their outstanding work and are true patient safety heroes. I’d like to introduce them:
Maxine has taken a special interest in preventing hospital-acquired infections. She is what the literature calls a “positive deviant”- someone who does the right thing and is an agent for good. She single handedly advocated for two new practices in the Neuro Critical Care Unit: 1) using a fresh rag to clean each separate piece of equipment in isolation rooms and 2) requiring terminal cleaning of the patient’s room once they were taken out of isolation. We know from lab cultures that Bell-Trusty has reduced the prevalence of multi-drug resistant organisms on her unit. While we often worry that the “bugs” are winning, Maxine has won the battle in her unit.
After a serious event involving a monitor alarm in 2006, Kelly’s unit set out to improve the safety of patients on physiologic monitors. They determined that 27,000 alarms were set off on their 15-bed unit every 24 hours- that’s one alarm every three seconds. Creighton worked with her committee and the Clinical Engineering team to improve the situation, reducing “nuisance alarms” by 26%. Kelly literally took the noise out of the system, so that nurses could respond more quickly to patients in trouble.
her unit. She found inexplicable changes in a number of patients’ sodium values. So she followed her instincts (and her intellect) that something was wrong with the laboratory findings being reported in a large series of patients. Working with the lab, an investigation found that more than forty patients in the Cancer Center had incorrect sodium calculations made. But thanks to Henderson’s astute observation and quick action, only one patient was treated for the incorrect results (without any adverse effects).
Vicki championed doing “re-vitals”- that is reassessing patients in the emergency department. In the past two years, she identified significant changes in patients. One was having a heart attack, and the other a stroke. Because of Vicki, these two patients received the required treatment from the heart attack team and the brain attack team earlier than they would have. When minutes count, Jackson’s vigilance was life-saving.
Sara is a new graduate who joined Hopkins in March 2008 and she has already demonstrated an aptitude for promoting the safety and well-being of the very ill patients under her care. For example, Nakamoto discovered that a pre-mixed IV solution had one medication label applied over another label. The IV bag actually contained the solution noted on the hidden label, and this drug was contraindicated for the patient. Nakamoto’s patient had impaired renal funcation with only one kidney, and could have suffered significant complications had the drug been administered. For this patient, Sara was a hero.
Working the tail end of the night shift, Liza was preparing a surgical patient as the first case for the operating room one morning. The patient complained of not feeling well. Liza assessed the patient, whom she identified as having symptoms indicative of an impending stroke. She organized the ophthalmology team and facilitated the patient’s transfer to the Emergency Department where the required treatment was rendered in a timely fashion. Her quick assessment and critical thinking provided an immediate intervention so that the patient with an impending stroke was managed in a controlled environment.
The Hospital has been implementing an electronic provider order-entry system requiring all physicians to enter their orders online, and all nurses to document administration of medications in an electronic record. While the system was designed to be safer than paper-and-pencil versions, it was not fail safe. Robertson orchestrated the collaboration between physicians and nurses that was needed to develop the order sets, and implemented the change across the Department of Surgery. Many safety issues have arisen during this process. Robertson monitors these, and drives safety issues to the top of the priority list for system modifications. While many of our safety heroes have prevented individual patients from being harmed, Robertson is working to make the whole system safer.
On a unit where children and adolescents are treated for psychiatric illnesses that cannot be managed safely out of the hospital, security is a critical concern. Gloria Scott worked with the Pediatric Safety Team to add a security officer to the unit. The lay security officer could maintain a presence at the front door; identify visitors to determine if they are authorized; check visitors’ belongings; and lock away valuable or unacceptable items. However, the security officer was also needed to help with patients in a clinically appropriate manner. Scott explained the unit to the officer, taught the officer how to handle patients, and otherwise implement this new role.
Because of Scott, the environment is secure and the patients are safer.
The stories about Melinda are legion. In summary, she “sees” problems and fixes them. To give one example, Walker recognized a set of safety concerns in the electroconvulsive therapy (ECT) suite. She subsequently prepared a 30-minute educational program covering how to prepare patients for ECT; transport anesthetized patients safely; and maintain a smooth flow of patients through the recovery phase. Her educational program has been incorporated into the annual review that all RNs must complete. Walker is a safety hero for preventing harm from befalling
(Thanks to Hopkins for providing the safety heroes’ stories!)