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First, Do No Harm
Marking a year since its launch, the Johns Hopkins Safety Stars program honors employees across the institution for ensuring safe practices.

   
 
 

Toni Alexander's empathy guides her work.

 
 

Jenny Helzer plays detective.

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Dorothy Harkless reconciles orders daily.

Toni Alexander knows first-hand what diabetic shock symptoms feel like. “Your eyesight suddenly blurs, your skin’s itchy, you constantly have to urinate and your balance is off,” she says. “It’s pretty scary.” So last November, when the core laboratory customer service technician saw a high glucose “panic value” in a diabetic patient, she acted swiftly, in hopes of tracking down the patient’s physician. But the result came to Alexander’s attention while she was on an evening shift. The on-call physician at the outpatient site (where the blood was drawn) did not have access to the patient’s phone number.

Undeterred, Alexander spent the next hour trying to find the patient’s contact information. She even took time the next morning to verify with the patient’s physician that he’d been notified of the glucose value and that the patient had been cared for. Looking back, Alexander, a 30-year Hopkins veteran, says, “I just try to treat each person as I would want to be treated.” Since then, she says her department has taken more steps to better link the system with satellite offices.

Last month, during an inaugural annual dinner to mark Patient Safety Awareness Week, Alexander and 24 other “Safety Stars” were recognized for their efforts to prevent harm to patients. Lori Paine, the Hospital’s patient safety manager, notes that after more than five years of raising awareness about safety, she’s seeing tangible results. “It’s wonderful that we’ve reached a point,” she says, “where we can shift from education to celebration.” 

Among the most common safety issues, says Paine, are medication errors, as Weinberg ICU nurse Jenny Helzer can attest. A year ago, a postoperative patient in the unit was on an insulin sliding scale and required central parenteral nutrition (CPN) for calories. Observing a sudden drop in glucose, Helzer checked medical and mechanical sources and deduced a problem with the CPN. She immediately pulled the CPN and shared her concerns with her supervisor. The lab confirmed that the bag contained unordered insulin.

Helzer, a 2003 Johns Hopkins School of Nursing graduate, says she felt like a detective. “After looking at all the patient’s numbers,” she recalls, “I couldn’t make any sense of the drop in glucose. I finally realized that the only thing different was the CPN bag.” Fortunately, she adds, the patient improved quickly and was released that morning. “I’m glad to be part of a new era of nurses who are encouraged to go with their instincts,” says Helzer, who was also named a Safety Star. “I’ve learned that it’s OK to challenge something or own up to mistakes.”

With that same mindset, Hopkins Children’s clerical associate Dorothy Harkless took action when she noticed that a patient’s epidural infusion orders were written based on a weight of 18 kilograms instead of 18 pounds. After 10 years on the job, Harkless, who verifies that names match patients and orders are valid in the “Accountability Book,” realized that a kilogram is 2.2 pounds, and the child could not have weighed almost 40 pounds, given its age. So Harkless asked a nurse for clarification. Thanks to that vigilance, the patient's epidural was stopped and new orders were written before any harm could occur. Harkless’ willingness to speak up prevented a possibly significant overdose and earned her a Safety Star award as well.

“Safety begins with persistence,” says Paine. And that sometimes means taking responsibility above and beyond one’s job description, adds Beryl Rosenstein, vice president of medical affairs. “The biggest surprise,” he says, “is that the people at all levels of care—system-wide—are beginning to appreciate how big a part they can play.” Indeed, the 25 Safety Stars represent 13 job categories. 


— Judy Minkove

 

For a complete list of Safety Stars and their stories, see insidehopkinsmedicine.org/stars/.
 
To nominate an employee for a Safety Star, contact Lori Paine at 410-955-2919 or lapaine@jhmi.edu.

 

 

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