Meetings held throughout Pennsylvania Hospital over the past year have opened with stories of near misses, good catches, and great practices learned from other locations. Encouraging staff to share their safety stories without shame or fear ensures that the safety of our patients remains our main focus. At last month’s Service Directors meeting, for example, nurse managers Chris Huot, MSN, RN, CNML, and Beth Ann Pyle, MSN, RNC-MNN, shared a story that began in the SICU, but rippled across units.
When a patient began suffering cardiac arrest, a recent addition to the nursing team pushed the blue button on their headboard, expecting it to alert the house-wide code response team — but at PAH, these buttons activate an in-unit alarm. Fortunately, staff were able to quickly resuscitate the patient, and the nurse took the time to share her experience at the Critical Care Unit safety review. Huot noted that this could be a house-wide safety concern, so our nurse educators created a huddle flash and encouraged nursing leaders to share it with their teams. Before Pyle had the chance to do so in the Mother Baby Unit, she realized that a charge nurse had already seen the huddle flash, recognized it as valuable information, and took it upon herself to print it ahead of their local safety review. To me, this story is a perfect example of what we can accomplish when every staff member is personally invested in patient safety.
Since 2018, PAH has been focused on building a fair and just culture based on transparency and trust. While the road to high reliability takes time, effort, and change, regularly sharing safety stories is an easy way to focus on why we’re all here. Hospital leaders like Patty Harris and Joanne Ruggiero, MSN, RN, MA, NE-BC, CMSRN, have been instrumental in rolling out this initiative, but every physician, nurse, lab tech, or food service worker who has prepared a story has also played a critical role in this cultural shift. Prioritizing safety means that everyone plays a part, whether they are at the bedside or not. The more openly we speak about successes and errors alike, the closer we get to high reliability. I am grateful for everyone’s continued efforts to share their stories, to reflect on their colleagues’ experiences, and to ensure the safety of every patient who walks through our doors.