The object was about an inch long, slightly curved and made of metal.
Radiologic technologist Sonia Santos couldn’t be sure what she was looking at, but she knew it didn’t belong in the abdomen of a 3-year-old child.
Santos had just performed an X-ray on Ezriel Kahan, a patient who would soon have open heart surgery at CHOP’s Cardiac Center. It was a busy day in Radiology, with many patients waiting for studies. In some other hospitals, a radiologic technologist might have passed the films along, allowing physicians to discover the shape and decide what to do.
Santos, who had completed CHOP’s safety behaviors training, was empowered to take action. She looked at the images again, checked carefully to make sure the object wasn’t somewhere on the outside of Ezriel’s clothing, then alerted radiologist David Mong, M.D., and cardiologist Chitra Ravishankar, M.D., of her findings. The next day a team of physicians surgically removed a metal hair clip from Ezriel’s stomach. Unbeknownst to his parents, the little boy had managed to remove the clip from his own hair, worn long at the time, and had swallowed it.
Santos’ prompt action averted a potential disaster: Following his X-ray, Ezriel had been scheduled for a cardiac MRI. Any metal in or on his body would have been attracted with incredible force by the machine’s powerful magnet. The result could have been serious injury or cardiac arrest.
Soon thereafter, Santos was surprised to learn that she had received a highly visible honor: the Hospital’s Good Catch Award. Instituted in 2012, the Good Catch program allows employees to recognize a colleague or themselves — no matter what their job — for an action that helped prevent harm.
“Good Catch helps connect CHOP’s safety efforts to employees in every role throughout the institution,” says Jeanette Teets, M.S.N., R.N., director of Patient Safety. “It’s an especially powerful way to engage employees who are not providing direct clinical care. They may see something, but hesitate to get involved.”
In the last year, the Good Catch program has received 580 nominations from 80 areas of the Main Building and CHOP Care Network, many from clinical staff, but also spanning disciplines as diverse as Environmental Services, Security, Food Service and Music Therapy. The program is just one of the ways CHOP is weaving a culture of safety throughout the entire fabric of the institution.
Safer All Over
Jan Boswinkel, M.D., vice president of Medical Operations and chief safety officer, looks Hospital-wide for ways to build systems that prevent errors. And many of the best come from front-line staff. “High-reliability organizations go where the expertise is to find new ideas,” he says. “For systems to work, they not only require collaboration across disciplines, they need to be owned at the local level.”
The Office of Clinical Quality Improvement, led by Ron Keren, M.D., M.P.H., is creating and measuring the impact of clinical pathways — protocols that standardize the way care is delivered for various diagnoses, greatly reducing the likelihood of medical decision-making errors.
Amy Ford, an Environmental Services employee, was honored with a Good Catch Award for interrupting patient rounds to alert the medical team to a potential safety issue. “Sometimes we don’t view ourselves as an important part of the team,” Ford says. “But we are.”
The Medication Safety team, led by Sean O’Neill, Pharm.D., has implemented bar coding among its efforts to ensure safety in an area whose volume and complexity could leave it vulnerable to mistakes.
More than 5,000 clinical staff have completed safety behavior training, aimed at improving communication skills and overcoming cognitive bias — that is, reaching conclusions based not on what they observe, but on what they’ve experienced before.
Looking beyond its own walls, CHOP is part of Children’s Hospitals’ Solutions for Patient Safety, a national collaborative of more than 80 pediatric hospitals that employ the “All Teach, All Learn” philosophy. As members of their own Patient Safety Organization, these pediatric hospitals find a protected environment where they are able to share safety events and collectively learn from them.
The Right Thing to Do
For Sonia Santos, “It was nice to be recognized,” she says, “but it’s really part of my job to stop and take a closer look when something doesn’t seem right.” And that, in a nutshell, is what the Good Catch program is all about.