Clinical resource leaders Cheryl and Tanya recognized for ‘good catch’ – how quick-thinking and teamwork led to preventing patient harm

“One in 18 patients experiences harm in Canadian hospitals.”

In 2016, this staggering statistic rocked news headlines across the country; and in doing so, reignited a crucial public conversation on preventable harm in hospitals.

This week is Canadian Patient Safety Week, which invites all Canadians – patients, family members, staff and physicians – to become involved in making patient safety a priority.

For Cheryl Nelson-Singh and Tanya Levit, Clinical Resource Leaders at Michael Garron Hospital, quick-thinking and an “independent double check” may have saved a patient’s life.

Recognizing that staff and physicians work every day to support a culture of safety, MGH’s Organizational Quality & Patient Safety team has launched a new recognition program for individuals who demonstrate behaviours aligned with the Hospital’s quality and patient safety plan. Priorities include: high-performing teams, early warning systems and speak up for safety.

Cheryl and Tanya are the first recipients of the new Safety Behaviour Recognition Program for their good catch which demonstrates the “early warning systems” safety behaviours.

“By celebrating staff and physicians who demonstrate these behaviours, our aim is to highlight great work, outline the expectations we have for staff, physicians and leaders and ultimately emphasize our shared accountability for keeping our patients safe,” says Mari Iromoto, Director of Quality, Operational Excellence & Innovation at MGH.

Looking out for potential safety issues

This fall, Cheryl and Tanya were delivering care to a patient and a high-alert medication was prescribed; this means that the drug carries a heightened risk of causing significant patient harm if used in error. This particular medication is available in three different concentrations (bags) at the Hospital.

While preparing the correct concentration for medication administration, Cheryl and Tanya initiated an ”independent double check”. Cheryl read the IV pump while Tanya read the calculation for the prescription, and they compared results to confirm the correct dose, concentration and infusion rate.

“Not checking the same thing at the same time helps to avoid confirmation bias,” explains Tanya.

There was only one concentration available as a pre-programmed selection on the IV pump. Numerically it matched the bag, but there were no units listed. It could have been presumed that the bag and IV pump were the same units.

But Cheryl and Tanya realized that the rates did not match: the bag calculation was in micrograms, while the IV pump was in milligrams.

The concentration that was required was not programmed on the pump as expected.

Cheryl and Tanya confirmed their calculation and entered it manually into the IV pump to begin infusion at the correct rate.

“We avoided under-treatment of four times less medication that would have occurred if the error had reached the patient,” says Cheryl.

Stepping up to keep patients safe

Following the event, Cheryl and Tanya escalated the safety concern to create organization-wide awareness and learning: they debriefed with the team, reported the concern to departmental leadership and the Quality & Patient Safety team and raised the concern during the Daily Safety Check.

Numerous meetings have been held with cross-hospital stakeholders and content experts to implement immediate interim solutions for the IV pump settings and to develop a long-term plan.

“This really emphasizes the importance of good catches,” says Narmin Hemani, Patient Safety & Quality Specialist, MGH.

“Errors that do not reach the patient should still be reported as the potential impact can be high; reporting enables us to proactively implement improvements to prevent future harm.”