Safety Stories: It Takes a Village

Ellen S. Deutsch, MD, MS, FACS, FAAP, CPPS
Medical Director
Pennsylvania Patient Safety Authority

The Value of Group Efforts

The origins of the aphorism that "it takes a village to raise a child" are uncertain,¹ but the meaning is clear: the contributions of many are required to achieve the best outcome. The same principle is relevant in healthcare.

Opportunities for patient harm are infinitely creative and can occur at any point in the healthcare delivery process. These narratives demonstrate how diverse people, with different roles, each contribute to making patient care safer:*

Patient's dose of insulin was modified during his admission, including adding a dose during meals. When the patient contacted his endocrinologist, he was told to take the larger pre-admission dose. The homecare staff recognized the discrepancy and supported the patient in clarifying the correct adjusted dose.

The nursing assistant recognized that a patient with diabetes was reusing lancets and reported this to the nurse practitioner. Further investigation revealed that the patient had become homeless and could not afford his testing equipment or medications. The patient was provided with education and resources prior to discharge.

Theultrasound technologist recognized that a patient who had arrived with a nasal cannula on her bed was not accompanied by an oxygen tank. The technologist confirmed with the patient's nurse that the patient should be receiving oxygen.

A physician called regarding a liquid formulation for a medication for a patient with difficulty swallowing. The pharmacist then inquired about the other medications the patient was receiving and was informed that several other medications were being crushed for easier ingestion. The pharmacist provided advice on appropriate formulations.

Heparin was ordered for a patient with an aneurysm and suspected bleeding. The nurse thought the order was inappropriate and contacted the provider, who realized that he had placed an order for the wrong patient. The order was discontinued and the patient did not receive heparin.

Patient in Med/Surg unit given a medicine cup with 4 pills. Patient was told that there were 4 pills and given water to drink with the pills. RN saw the patient place the pills in his mouth and the patient returned the empty medicine cup to the nurse. 2 hours later the patient's mothernoticed that 1 of the pills was on the floor, and she alerted staff.

Test results were being placed on the wrong patients' charts. Information management personnel noted that this happened in more than one unit and involved multiple staff members. Staff are evaluating the documentation process to remove unnecessary steps that can lead to mistakes.

After the patient arrived in the operating room, the surgeon reviewed the radiologic studies and recognized that the consent for surgery stated the wrong spinal levels. A consent for the correct levels was obtained.

The examples presented are a sampling of many event reports about professionals, support staff, family members, and patients who recognize and correct a patient safety hazard.

Safe healthcare delivery is a complex ballet of participants with diverse knowledge and skills who cooperate and collaborate with each other in the shared goal of providing safe healthcare. No matter what our roles are in healthcare delivery, each of us can contribute to patient safety.

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* The details of the Pennsylvania Patient Safety Reporting System event narratives in this article have been modified to preserve confidentiality [emphasis on occupations added].

Note

1. Goldberg J. It takes a village to determine the origins of an African proverb. [internet]. Washington (DC): NPR.org; 2016 Jul 30 [accessed 2018 Aug 07]. [3 p]. Available: https://www.npr.org/sections/goatsandsoda/2016/07/30/487925796/it-takes-a-village-to-determine-the-origins-of-an-african-proverb.