Patient Safety Heroes Save the Day

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By Karen Haller, PhD, RN, FAAN

VP of Nursing and Patient Care Services, Johns Hopkins Hospital

Many at Hopkins know the story of Josie King, the 18-month old who died at our hospital from medical errors in 2001. Her parents experienced overwhelming sorrow and intense grief, but were also consumed with anger. Mrs. King has said that anger can do one of two things to you: “It can cause you to rot away or it can propel you forward.”

In the years following Josie’s death, Sorrel and Tony King moved forward and created the Josie King Foundation to unite healthcare providers and consumers, fund innovative safety programs, and create a culture of patient safety. The foundation funds an annual patient safety research award of $10,000 during Nurses Week; and hosts a luncheon for our patient safety heroes.

Who are patient safety heroes? They are individuals who have actively prevented harm to our patients. The literature calls them “positive deviants”-those among us who do the right thing and are agents for good. Nine individuals were identified by their nursing departments as having been a positive force to make healthcare safer.

The Department of Gynecology recognized Sara Nakamoto-a first-year nurse-who discovered that a pre-mixed IV solution delivered to her unit had the incorrect medication label applied over another label. The IV bag actually contained the solution whose label was hidden, and was contraindicated for the patient. Nakamoto’s patient had impaired renal function, and could have suffered significant complications had the drug been administered. For this individual patient, Nakamoto was a super hero!

Kelly Creighton was recognized by the Department of Medicine for her work on improving the safety of patients on monitors. Creighton determined that 27,000 alarms rang on her 15-bed intermediate care unit every 24 hours-that’s one alarm every 3 seconds!  Creighton worked with her committee and the Hospital’s clinical engineers 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.

For a complete list of this year’s Patient Safety Heroes, go to www.josieking.org/blog/.

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