Jack responded to an RRT called on the ortho unit when the staff was having trouble obtaining a blood pressure on a patient experiencing dizziness. After quickly assessing the situation, Jack performed a more thorough assessment, noticing bruising on the patient’s arm and muffled heart sounds. Jack’s findings prompted him to continue to investigate the situation by asking the family members about the patient’s bruising. Jack and the team then found out the patient had recently had a pacemaker placed. Jack knew that something was not right, and promptly notified the cardiology team and advocated that the patient be transferred to the ICU for further care. As the patient’s condition quickly deteriorated, Jack did not stop advocating for the patient and expressing his concerns that she was having a pericardia effusion. Dr. Silva was notified of the patient’s condition and almost immediately scrubbed out of the Operating Room to perform a bedside pericardia tap to relieve the pressure on the patient’s heart. The patient immediately gained color and her blood pressure returned. The end result could have been much worse if Jack were not there to pick up on subtle changes in patient status and serve as a patient advocate. Jack’s leadership and critical thinking skills helped staff function as a team and ended in a positive patient outcome.
What safety behaviors did the employee display?
- Pay attention to detail (STAR, peer
- Practice with a questioning attitude (Validate and verify)
- Speak up for Safety (5:1 Feedback,
If you would like to nominate someone as a safety champion, the nomination form can be found on the intranet (Intranet>Occurrence Reports>Safety Champion Nominations).