Patient Safety: Lessons Learned
“Good Catch” for Patient Safety

In its commitment to safety, Stanford Health Care relies on every individual to use the Stanford Alerts for Events (SAFE) reporting system to communicate when something might not be working correctly. Recently we had two great examples of situations where physicians and staff identified something wrong, reported it and helped Stanford address the issue to prevent patient harm.

Insertion kits–not as easy as 1-2-3
In reviewing catheter insertion practices, the Cath lab staff noticed something different in the Foley catheter insertion kits. The betadine and foam sticks were missing and in their place were three betadine swab sticks. An astute manager and nurse reported it to the SAFE system that day. Stanford’s patient safety and infection control team followed-up and discovered that there was an entire lot of catheters that had this less than optimal substitution. The issue was promptly escalated at the T4 huddle and procurement and operations acted to remove these kits from stock.

At the same time, an ICU nurse discovered one of the vents on the Foley catheters was not working properly. Again, concerned that patients could get CAUTI from the faulty device, she reported it and Stanford was able to remove the affected lots from stock. These two issues were reported to the manufacturer and CDC/ National Healthcare Safety Network (NHSN) and these individuals were awarded a patient safety award for their focus on keeping patients safe.

What to do if you suspect something isn’t working properly:

• If it is a device, ensure that unit/clinic management sequesters the device, and follow instructions (here) to contact Risk Management and file a SAFE report.

Pump failure
It is not uncommon for providers and staff to rely on battery-powered devices as we ready patients for transport between care settings. Recently, an anesthesiologist noticed an issue when readying a patient for transfer out of the operating room. Soon after unplugging the device it shut down completely. She immediately reported this to leadership with concern that it happened, and that it might happen again. The pump was set aside for the manufacturer to review and reported as a SAFE event in the system.

Upon further review, numerous pumps were found to need batteries replaced. The issue was escalated in the T4 huddle and to the newly formed executive safety council where senior medical and operational executives review open safety issues that need resolution. Nursing, anesthesia and quality teamed up to produce a “patient safety alert” to communicate the issue as pumps were located and being fixed. Biomedical engineering acquired the batteries and worked in partnership with nursing to immediately take pumps out of circulation and perform the replacement and functional check.

What to do when an infusion pump/biomedical device doesn’t work properly:

• Ensure that unit/clinic management sequester the equipment immediately and correctly tag it for examination by biomedical engineering. Follow instructions (here) to contact risk management and file a SAFE report.

Patient Safety is essential to quality of care. We encourage everyone to speak up and report potentially unsafe situations so we can continue to make it easy to do the right thing for our patients every day.

For feedback or questions, please reach out to Lisa Schilling, VP Quality, Safety and Clinical Effectiveness at lschilling@stanfordhealthcare.org or Dr Sam Shen, Patient Safety Officer at sshen01@stanford.edu.