Patient Safety Star Highlights

Mass General Hotline recognizes three more Patient Safety Stars this week, Massachusetts General Hospital staff members who have gone above and beyond the call of duty to provide a safe care environment for patients, visitors and staff.

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Chinese Medical Interpreters Team

Last year, a disparity report identified opportunities for increased hospital engagement for the patient population who self-identified as Asian. Chinese patients make up much of that group. The Chinese Medical Interpreters Team—Juhui Mo, Andrea Zhu and Wayne Chen—then met with their director to understand the report and define possible strategies to address the disparities. The interpreters applied the strategies to achieve a new level of excellence in advocating for the safety of their patient population by helping providers communicate critical information. In one example, the team assisted a patient undergoing extensive cardiopulmonary tests. The provider had taken discharge instructions for the patient and put them through an online translator. The interpreters identified several concerning errors in the instructions, correcting some of the major mistakes before sharing them with a translation specialist who could facilitate an authenticated translation. The Chinese interpreters then collaborated on an appropriate translation of the discharge instructions which will be available to all patients who undergo these tests at Mass General.

Jeffrey Wahhab, RN

Jeffrey Wahhab, RN—who often serves as a resource nurse on the busy 26-bed medical unit on White 8—went above and beyond in creating a safe environment for a patient with advanced dementia and delirium who was a high fall risk. Wahhab felt it was important to have the patient rest in a low bed and, in the interim, utilize the bed alarm monitoring system. When he attempted to engage the alarm, however, he found he was unable to centralize the bed for alarm monitoring and notification at the nurse’s station. Throughout the night, Wahhab continued to troubleshoot the issue, finding two more beds with similar safety monitoring issues. To ensure these beds did not remain in use, he removed the equipment from circulation, tagging each item and using alternative devices to keep his patient safe. He then alerted unit leadership and worked together with Mass General Buildings and Grounds as well as Materials Management to assess the beds, the alarm cables and head wall. As a result, there are ongoing efforts—both on the unit and across the hospital—to increase awareness and address these issues.

Hospital Medicine Unit’s Albright Orange Team

The Hospital Medicine Unit’s Albright Orange Team cares for complex patients with extended lengths of stay. After a nurse practitioner reported and completed a safety report regarding a medication that expired due to the length of the patient’s admission, the Albright Orange Team restructured its practice for medication reconciliation. The clinical service line now dedicates 60 to 90 minutes to review every Albright Orange patient’s orders, including their medications. This review is documented weekly in the patient’s chart. The improvement has been tracked by “spot surveys” of the Albright Orange team and survey data reveals that medication and order errors are now recognized and resolved as a result of this practice change.