Changemakers: Stories That Made a Difference
​​​​​​​​​​​​​​​​​​​​Pennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also can be tools to trigger change facilitywide—or even nationwide.

Click one of the categories below or type keywords into the search field to find stories of event reports that inspired staff to make changes that improved patient care and safety throughout their hospital.

Featured Story
Refrigerators holding bags of blood.
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In response to an emergent blood transfusion scenario, emergency department (ED) staff followed policy and contacted the blood bank to start the unmatched blood acquisition process in case rapid transfusion was needed. However, once the order was received, the blood bank encountered several barriers to complete the request. When the ED was unable to contact the required personnel, a bedside clinician had to leave the unit to investigate what was happening in the blood bank. The clinician discovered that laboratory personnel were not receiving phone calls and pages as they were covering other critical areas. They informed the ED clinician that they had just received a call that the blood transfusion would not be needed and that the process was no longer indicated.

While any crisis was averted, this near miss incident demonstrated a lack of escalation process for this type of scenario, prompting a team of medical providers; nursing, laboratory, and blood bank staff; and quality staff to implement an action plan. During a cause-and-effect analysis, the team identified contributing factors: The event occurred on an off-shift that was experiencing staffing challenges, such as interdepartmental cross coverage, and unexpected telephone and information technology issues prevented communication.

To prevent future barriers related to information technology and assure prioritization of the requested intervention could be clearly communicated, the team enacted a “Code Blood Bank” response. In a situation where stat blood may need to be prepared and administered, Code Blood Bank is called on the overhead paging system. This alert will be heard in all areas of the facility to alert blood bank personnel of what and where the need is.

In addition, the team improved the telephone escalation process. The assigned remote phone for these emergent situations will be called and will ring a set number of times before transferring to the next staff member’s phone. If not answered by that member, the blood bank desktop and department cordless telephone will ring. If not answered in four rings, the phone will transfer out to the general laboratory area.

The blood bank staff were educated that if they leave the office for any reason, they must bring the remote telephone with them. All providers and nursing staff were oriented to the process, ensuring that they do not hang up after only four rings when contacting the blood bank. Communication officers were also educated with the process and its rationale.​


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