In hospitals, we use many forms of communication to transition our patients safely through their treatment process. We communicate at team huddles, through charting, and through identifiers such as signs outside patient doors, and wrist bands to identify falls risks and allergies. All of these are examples of how we share vital information to provide safe patient care.
In 2016, Sevim Vurgun, a Clinical Nurse Specialist in Surgical Oncology at Mount Sinai Hospital noticed that the unit had received a different style of allergy band than usual. These red bands are one of the ways the clinical team communicates that a patient has an allergy. This is critically important for when patients may not be able to communicate the allergy themselves or are being taken off the unit for a test or procedure.
These new bands required the care team to document the allergy using a particular type of marker. And even with that marker, the information could be easily rubbed off or smudged.
Sevim understood that this could pose a serious risk to patients if these bands were deployed, so she filed a near miss, safety event report. “I think the importance of reporting near miss incidents is underestimated. Near miss safety reports are indicators of potential safety risks, therefore they are taken seriously. They are reviewed and appropriate corrective action is taken to prevent future safety risks,” said Sevim.
On July 4, Sinai Health will be going live with the SAFER (Safety And Feedback Event Reporting) system at our Bridgepoint and Mount Sinai Campuses. SAFER is conveniently accessible to anyone with a network log-in and will help us gather data about all patient safety events and feedback to design systems to eliminate preventable harm as well as improve the experience for our patients and family caregivers.
Thanks to Sevim, the new allergy band was never implemented. This earned her a well-deserved Good Catch Award in 2016. When asked what she would want others to think about when they are considering filing a report, Sevim had this to say, “We are all experts in our own practice, so when something doesn’t seem right – trust your instincts and take a minute to report it.”