Heal without harm: If something doesn’t seem quite right, question it

December 2, 2014

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Texas Children’s cares for some of the country’s most critically ill patients, and safe, quality care for every patient is the most important responsibility of each staff member and employee here. Equipping our staff and employees with the knowledge and tools to take preventive action is key to creating an environment of safe patient care.

In an effort to illuminate the importance of everyone’s role, each month we will share patient safety stories that help heighten staff and employee alertness and accountability and, ultimately, reduce harm. This month’s story is a reminder that being familiar with your surroundings and knowing what to do in an urgent situation can help improve the outcome.

Jason* was a relatively healthy 9-year-old boy when he was admitted for a routine operation. After the procedure, he went to the PACU for recovery. There, a PACU nurse noted Jason’s ECG monitor tracing looked unusual. An electrocardiogram (EKG or ECG) is a test that checks for problems with the electrical activity of the heart and then translates the heart’s electrical activity into line tracings on paper.

The nurse asked the anesthesiologist to review Jason’s ECG tracing, and shortly afterward, Cardiology was called. Jason was evaluated and diagnosed with Wolff-Parkinson-White (WPW) syndrome, a rare heart condition that causes rapid heartbeat and has been associated with sudden death.

The nurse’s attentiveness made the diagnosis of WPW possible. Jason had a corrective procedure this summer. The subsequent evaluation and the procedure will help ensure that he does well with this diagnosis and has the best possible outcome.

Actions everyone can take:

  1. Ask a question. If something doesn’t look quite right – whether it’s an issue with a patient, coworker or a process – question it.
  2. Request a change. Identify the person who can help you change the situation, and bring the matter to their attention.
  3. Voice a concern. Don’t dismiss your intuition or assume someone else will notice the problem. Your voice might be the life-changing difference for a patient.
  4. Go up the chain of command. Always know that you can go up the chain of command if necessary to bring the matter to someone else’s attention.

* Patient safety stories are based on events at Texas Children’s Hospital. Patient names and some of the circumstances of the event may have been changed to protect patient privacy.

For the latest quality and safety information, visit the Patient Safety website on Connect.