As part of the MGH’s commitment to quality and safety, Hotline will feature each of the 50 Patient Safety Stars throughout the remainder of the year, highlighting a portion of their standout nominations.
Joshua Hirsch, MD, director of Neuroradiology in Interventional Radiology
Hirsch spearheaded the TEAM Operations Committee for advocating and practicing patient safety. This work, which includes a pre-procedure brief and post-procedure debrief in Interventional Radiology, has significantly improved communication and clarity between team members and allows members of the team to raise concerns without fear of repercussions.
Jessica Botelho Houston, assistant in the Surgical Pathology Lab
Houston received a request for additional tissue and noticed a potential mix-up in the grossing process. Her discovery allowed the issue to be remedied before it affected any patients. As a result, she built a platform to promote transparency of issues and bring awareness and accountability to errors made within the department.
Emily Hughes, MD, of the Department of Medicine
Hughes promotes patient safety through superb patient care and identification of areas that need improvement. She helped to identify medication safety issues in computer programs POE and CAS that led to reviews and a better understanding of how these processes will appear and work in Epic. Hughes is recognized in her department for her clear and succinct patient discharge instructions. Her work on this is used as an example for all the current hospitalists.
Kristen Kingsley, RN, of the Respiratory Acute Care Unit on Bigelow 9
Kingsley is recognized for her clinical expertise and leadership in the Patient Care Services Collaborative Governance Policy, Procedure and Products Committee. She is known to review evidence in order to lead a discussion and engage others. She brings the eye of the clinician to the bedside, promoting patient safety as well as seeking out content experts to aid in discussion. Hughes led a discussion regarding urinary catheterization in men over age 60, worked to update the policy and procedure and then assisted in educating and training nursing staff.
Sheila Leonard, surgical technician at MGH Danvers
Leonard’s work in a gastroenterology case is a great example of a culture of safety where one may truly speak up without fear of retribution, as she recently identified a bio-burden when setting up equipment. This led to practice improvements in the Operating Room and in Sterile Processing.
It is amazing the difference one voice can make.
Kristen Livesey, MD, of the Department of Medicine
Livesey was troubled by a poor outcome for one of her patients and used the event to highlight vulnerability in the current practice model.A patient at risk for alcohol withdrawal was admitted to an inpatient medical unit and developed severe withdrawal. Livesey advocated strongly for the introduction of Clinical Institute Withdrawal Assessment for Alcohol (CIWA) training to both physician and nursing staff, and she has enthusiastically agreed to participate in CIWA training for hospitalist staff.
Read more articles from the 06/17/16 Hotline issue.