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INTRODUCTION

For safety is not a gadget but a state of mind.

 —ELEANOR EVERET

 

Here's a one-item quiz for everyone in your organization: "Who is responsible for safety?" Of course, the right answer is "me." Unfortunately, quite often the answers you'll hear will involve a person whose title has the word safety in it. At UCLA, Erik Eggins is an individual who fits that description, given that his name badge reads "Director of Safety." Erik notes that a healthy safety culture is reflected by the commitment to safety demonstrated by each individual in the organization every day. "I appreciate that at UCLA we actually talk about safety in the context of culture, and as such we have encouraged all staff to take an ownership position in championing projects. Such safety initiatives serve the well-being of our patients and staff members. Rather than having a top-down approach to safety or feeling that people view me as the 'safety advocate,' a passion for our shared security is broadly held throughout our organization." The reality of a safe work environment involves safety initiatives that emerge from the engagement of front-line workers.

One example of this level of proactive involvement occurred a number of years ago when Robin Rosemark, RN, MN, clinical nurse specialist, jumped in to improve performance on a routine patient transfer process. Robin notes, "An escort came to pick up a patient for an ERCP, an invasive procedure. I had read the physician's notes and knew about the likely occurrence of the procedure, but there was no written order for it. I was working with a new nurse, and I asked her, 'Do you feel it is safe to send the patient with the escort for the procedure?' She responded, 'Yes, why not?' to which I answered, 'Well, there isn't a physician order in the chart.'" That one incident sparked Robin to take the matter to Dr. Tom Rosenthal, chief medical officer, to see if a safe process could be defined.

According to Robin, "Working with Dr. Rosenthal, we embarked on a hospitalwide change to promote safer practice in patient identification. Often, scheduling of tests and procedures was done physician-to-physician. But a critical element was missing at times, and that was the actual tangible order in the chart—the missing thread of communication that ties all the loose ends together. We appreciated that the conditions for error existed because of a lack of consistency and uniformity in documentation and handoff."

To rectify the situation, Robin investigated best practices on patient identification protocols and the need for two confirmed identifications of a patient. Additionally, she looked at the breadth of situations across UCLA Health System in which these types of handoffs could occur. Robin notes, "I surveyed the patient identification process in the main operating room, main radiology, CT, MRI, interventional radiology, cardiac catheterization suite, bronchoscopy, ...

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