PA PSRS Patient Saf Advis 2007 Dec;4(4):146.
Hats Off to the Unsung Heroes

One of the unique features of the PA-PSRS program is that it receives reports not only of Serious Events (adverse events), but also Incidents (near misses). No other state requires the reporting of Incidents, which account for about 96% of all reports submitted to PA-PSRS. Since its inception in June 2004, PA-PSRS has received more than 600,000 near-miss reports.

This database is rich with examples of how healthcare workers have promoted recovery from medical errors and prevented patient harm. However, what is interesting is that many times patient harm was prevented by someone other than the healthcare worker who was most directly involved with the error; that is, someone who might not ordinarily be seen in the role of preventing the patient harm that a specific error might produce.

The exciting thing about these reports is that these healthcare workers went beyond their job description—“It’s not my job” did not seem to be in their vocabulary. They took it upon themselves to go the extra mile for the sake of patient safety.

For example, hundreds of PA-PSRS reports involve discontinuity of ordered oxygen therapy during patient transport from one department to another. Ordinarily, prior to transport, the nurse is responsible for ensuring that the patient is properly set up with a source of portable oxygen. However, in many instances, a transporter informed a nurse of an incorrect oxygen set up, after which this error was corrected by nursing. Transporters have found problems in every phase of oxygen delivery, including cannulas not applied, oxygen tubing not connected to portable oxygen tanks, regulators not turned on, tank valves unopened, and empty or extremely low supply in oxygen tanks. Transporters who spoke up—telling the nurse of their concerns—have prevented many patients from developing respiratory compromise.

Here is just one example.

A transporter arrived to pick a patient up for an x-ray. The patient was in a chair with a nasal cannula applied with oxygen tubing attached to a portable oxygen tank. The transporter asked the nurse to complete a form indicating that the application of the patient’s oxygen was correct. After the nurse signed the form, the transporter noticed that the oxygen valve had not been turned on.

Another example involves phlebotomists. Again, in hundreds of reports, phlebotomists have discovered patients without identification wristbands. The phlebotomists have notified nursing who, in turn, confirmed patient identification and applied proper wristbands. While the phlebotomist was delayed in drawing blood specimens on these patients until after the wristband was applied, these healthcare workers performed a valuable service, ensuring that wrong patient errors were less likely to occur as a result of their intervention.

Unfortunately, on rare occasions, these efforts to prevent patient harm have not been positively received, as evident in the following PA-PSRS report.

During morning lab draws, the lab tech discovered a patient had no identification band. The tech notified the clerk, who got a band and asked the tech to band the patient. Because the tech did not know the patient, he asked a nurse to come to the patient’s room. The nurse banded the patient without identifying the patient, stating she was not the patient’s nurse and didn’t know the patient. Because the patient was not oriented, verbal identification from the patient was impossible. The lab tech returned to draw the specimen when someone was available to accurately identify the patient.

What is important to remember is that all staff in a healthcare facility can really make a difference. Respecting and acting appropriately when other personnel present concerns not only promotes teamwork but also enhances patient safety. Other personnel who may not have primary responsibility for such things as oxygen maintenance or patient identification are part of the healthcare team. They can be the eyes and ears to identify important patient safety issues and report problems to the appropriate healthcare team member who can resolve it.

So, hooray for these unsung heroes and continue your good work!


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