I AM Patient Safety 2019: Safety Story (Near Miss or Close Call) Award

Stacy Green
St. Christopher's Hospital for Children

While caring for a patient at St. Christopher's, registered nurse Stacy Green heard strange popping from beneath the child's bed. When she investigated the noise, she discovered a stripped and frayed power cord—which was sparking dangerously. She immediately assured the patient was safe and unharmed, and notified biomedical services and her supervisor. The bed was quickly taken out of service, and she submitted a safety event report, which was shared along with photos of the damaged electrical cord the next day at leadership's daily safety huddle. As everyone grasped the urgency and risk to patient safety, the biomedical and quality department embarked on an audit of every patient bed. Armed with a script to discuss the inspections with concerned patients and families, the inspection team found three more beds with damaged cords and removed them from service. The incident and timely response from Stacy, hospital leadership, quality staff, and biomedical staff prompted a new protocol: The Environmental Service department now inspects patient bed electrical cords when they clean rooms following a patient's discharge. The hospital also reported the incident to the U.S. Food and Drug Administration's Medical Product Safety Network. Subsequently, the bed manufacturer investigated the incident, replaced the frayed cords at the facility, and issued a national alert to their customers with guidance on correct cord storage, inspection, and replacement. Thanks to Stacy's commitment to a culture of safety and timely safety event reporting, hospital leadership was able to take action to prevent patient harm in her organization and possibly others.

 

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