Armed with a passion for protecting patients, bedside nurses are the unit’s natural safety leaders

In the calm following the evening baths, a teenage patient glowers as he watches cartoons and eats a homemade fruit cup. He waves the plastic spoon aimlessly as the other children giggle at the antics on TV. From a nearby wall, nurse Thomas Koenig watches carefully as the teen begins to bang the spoon into his palm—slowly at first—but then faster and faster, until he grabs both ends and violently snaps the spoon with a loud crack.

Koenig is on a tiny walkie-talkie before the younger kids have time to startle. An escort arrives in seconds to whisk the angry patient out of the room. And just like that, order returns to the child and adolescent psychiatric unit.

Less than a year ago, the situation would have forced Koenig to turn his back on the patient and yell down the unit’s long hallway for the escort. When caring for children suffering from abuse, suicidal thoughts or even hallucinations, maintaining a secure and therapeutic milieu is crucial. Such potentially serious outbursts led nurses to propose the two-way walkie-talkies as a faster—and safer—way to communicate that help is needed. Within a week, their request was granted.

Throughout the hospital, bedside nurses are using their front-line positions to identify potential patient harm situations and contribute to their solutions. And hospital leaders are listening. In an era where fixing faulty systems—not blaming individuals—is fundamental, the traditional hierarchy of health care is dissolving. From taking their place at decision-making tables to teaming up directly with executives, bedside nurses are forging leadership roles in the battle to deliver top-notch, cost-effective and patient-protective care.

Julia Paganini discovered her knack for fingering medication errors early on. As a new graduate on the infants unit, she occasionally saw chemotherapy orders missing decimal points. Still resonating was the memory of toddler Josie King, who died in 2001 as the result of an error that went unchecked.

So Paganini alerted the unit’s safety representative, the nurse that everyone went to with safety issues. “I not only felt comfortable going to her, I wanted to be her,” she says.

The safety rep nurtured her interest, and now Paganini is that unit’s safety rep and chairwoman of the Josie King Safety Team. Funded by the patient advocacy foundation Josie’s mother created in her daughter’s honor, the team meets biweekly to discuss dangerous situations and to hammer out the protocols that will keep a danger from becoming an error.

Paganini leads the meetings, which are attended by pediatricians, the chief resident, the director of pediatric nursing and several pharmacists. “The team believes that every nurse’s concern is an important one,” she says. “It’s made me realize how much impact we really have.”

One of the most critical safety issues on the infants unit is proper patient identification. To protect those who can’t speak up for themselves, the safety team spearheaded a movement to step up staff awareness of the importance of ID bands and began conducting random audits to check compliance. Signs are now posted at each bedside: “Hello, My name is (blank). Please check my ID band. If I am not wearing one, please tell my nurse.”

The team’s most recent project, still in its nascent stages, is rewriting the protocol for delivering peripheral alimentation solution (PAS). Nurses found that when inserting peripheral lines into infants’ arms, they ran the risk of bursting their tiny veins and releasing the corrosive solution into the surrounding tissue. Now, the team is considering a switch to central lines to prevent that from happening. “We’re also using it as an opportunity,” says Paganini, “to educate nurses and physicians about possible tissue damage when delivering PAS through peripheral lines.”

Like Paganini, medical progressive care nurse Melinda Sawyer also seemed to have a natural aptitude for spotting harmful situations. “When I first started here, I was always catching and reporting medication errors,” says Sawyer. “My nurse manager finally said, You have a real knack for this. Why don’t you start a committee?”

She did, and five years later Sawyer is more than just her unit’s safety officer. She has also gained the ear of Hopkins Health System’s chief financial officer through a safety-focused, suits-meet-scrubs initiative. The Comprehensive Unit-based Safety Program, or CUSP, began as a way to both evaluate the local safety culture and boost staff morale in the hospital’s high-stress, high-turnover intensive care units. A hospital executive “adopts” an individual unit, participating in monthly meetings to analyze incidents and target defects in patient-care systems. In return, the staff has direct support from the highest levels.

Sawyer’s unit is the first non-ICU to be adopted. (She volunteered to pilot the program’s expansion.) At the last CUSP meeting, Sawyer presented a nursing concern regarding an inconsistency in respiratory therapy orders to CFO Ronald Werthman. There seemed to be a disconnect in communicating orders to agency respiratory therapists, Sawyer related. Werthman wondered: Why is there a respiratory therapy shortage and what is the hospital doing about it?

“He raises the big-picture questions that we’re too focused to know about,” says Sawyer. “And his sheer presence on the unit empowers staff. They feel like their concerns are being heard at the top.”

Werthman learns from Sawyer, too. She clues him in on clinical jargon and informs him of recurring problems. Through e-CUSP, the online component that Sawyer uses to organize and share her unit’s safety projects, Werthman can stay updated and keep an eye out for ways he can use his position to cut through red tape. “Folks really look to Melinda to identify the initiatives, structure them and monitor their performance,” says Werthman. “She certainly commands my respect.”

Sawyer is currently in the midst of a problem surrounding the alarms that saturate the unit. Between the two-way pagers, bed alarms, heart monitors and others, it’s all too easy for nurses to become desensitized to the constant buzzing and miss one that’s truly important. Werthman has offered his support in expediting any clinical engineering orders that may result from Sawyer’s data collection. When the project is completed, Sawyer can use e-CUSP to share lessons learned with other hospitals.

“CUSP has not only given me a voice to speak up about safety issues, it’s given me the tools to fix them,” says Sawyer. “Not many nurses out there can say that. We’re truly creating a new standard of safety for other hospitals to follow.”

PHOTO:  MPCU nurse Melinda Sawyer relates a safety concern to CFO Ron Werthman.

-From Hopkins Nurse, Spring 2005