VHA National Center for Patient Safety

Cathy McCormick, R.D., certified diabetic educator, and Julie Persinger R.N., orthopedics, stand in front of a display of "I Care" awards recipients, located in one of the facility’s main hallways. The board is updated monthly and notes important categories of performance, such as integrity, commitment and advocacy.

Each month our facility's “I Care” awards program recognizes an employee for distinction in one of five categories of performance: integrity, commitment, advocacy, respect and excellence.

The two examples below – using the “Stop the Line” technique ­– indicate how the award is often directly related to enhancing a facility’s patient safety efforts.

Preventing a Rare Dosage Error

Dietician Cathy McCormick has been commended for her commitment to patient care and to patient safety. Recently, she demonstrated how to “Stop the Line” when she recognized a patient was taking the wrong insulin.

He was taking an ultra-rapid acting insulin when other care givers thought he was taking a combination of quick-acting and long-acting insulin. Cathy questioned the patient, examined the medication containers and immediately contacted pharmacy. Based on her report, pharmacy quickly determined the precise cause of a very unusual and complex electronic error.

Although the error had been in the system for some time, it had never come to light because of its unusual nature. A provider and/or a pharmacist would not have readily recognized the error of this rare a type in the medical record.

Pharmacy quickly ran a report to determine if other patients had been affected by this issue. Three patients were identified; thankfully, only one had been impacted by this problem.

Cathy was KEY to identifying a hidden system error that, if not identified and corrected, could have potentially had an extremely negative impact on a number of patients.

When a Medical Device Gets it Wrong

Julie Persinger, R.N., has been commended for her commitment to patient care and to patient safety.  She, too, effectively “Stopped the Line” when she questioned, explored, and communicated what she perceived to be new, consistently elevated test results – that appeared out of line with the patient’s previous results

Her clinical knowledge allowed her to recognize this anomaly, but it was her follow through and reporting that made the difference. Her perception was correct. In this specific event, all of the quality checks on the medical device used to determine the results indicated “all was well,” but that was not the case.

Based on her concern, additional exploration and testing were conducted and proved human assessment and judgment had triumphant over a medical device’s report.

The device has been repaired and is functioning appropriately. A report that the machine malfunctioned, yet passed all quality checks, is being forwarded to the FDA.

Julie’s quick action allowed an immediate and thorough review, not only of the device involved, but of all patient care that may have been impacted.

Fortunately, in this case, there was no harm to any of our Veterans.  Had she not reported her concern to the appropriate persons the outcome could have been very different. Julie was the KEY to unlocking and correcting a safety hazard and enhancing patient safety at our facility.

Making a Difference

Rewarding staff for finding and acting on a medical systems-related problem is a great way to promote patient safety and employee morale.

The more employees who are willing to speak up about a potential patient safety issue, the better quality of care we can offer our Veterans.

Learn More

About the facility: Cincinnati VAMC

Read a TIPS article: “Stop the Line for Patient Safety”