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Quality Update - What an idea!

Winter 2011

What an idea!

Date: January 20, 2011

An employee recognition program targets "Safety Stars."


When Jessica Crow opened the emergency drug box to find medication for a patient going into cardiac arrest, the clinical pharmacy specialist made another, alarming discovery. There were no vials of magnesium, an omission that could be life-threatening in another emergency. So she reported her finding, which increased institutional awareness about the need to regularly check these boxes’ contents.

For her action, Crow was honored with a Johns Hopkins Safety Star, an award recognizing hospital employees whose exemplary actions have prevented medical errors and identified hazards. Recipients get a customized lapel pin, a congratulatory letter from hospital leaders and their stories told in institutional publications.

The program is a way to celebrate a growing culture of safety at the hospital. Because many Safety Star-worthy actions are first identified through the hospital’s adverse-event reporting system, Patient Safety Net, the program also reinforces to the hospital community that their reports are reviewed and acted upon.

Since the program was launched in 2007, roughly 50 employees have won Safety Stars—reflecting the high bar set for the actions that merit it. Recipients include nurses who challenged medication orders that were later found to be incorrect, a clerical associate who spoke up when she realized that a patient’s infusion orders were written for a patient who weighed 18 kilograms when her real weight was 18 pounds, and a physician assistant who, on her own time, delivered an auditory glucometer to the home of a blind diabetes patient so he could accurately measure his blood sugar.

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