Thursday, April 23, 2009
Caller-Outer of the Month Award #4
Our Board of Directors met yesterday and presented their fourth Caller-Outer of the Month Award. There were two recipients, Holly Dowling and Susan Keefe, nurses in our hematology-oncology outpatient clinic.
As I have noted previously, the purpose of the award is not to recognize someone who has solved a problem, but rather to recognize someone on the staff who has noticed a problem and called it out. The idea is that call-outs lead to root cause analyses that enable us to fix problems systematically rather than engaging in work-arounds. Our Board of Directors created the award as part of our BIDMC SPIRIT program to encourage people to call out problems to make our hospital a better place to work. (Beyond the recognition, the award is accompanied by two really good tickets to a Red Sox game.)
The story here was that Susan, a new employee, noticed that the rubber gloves she was asked to wear in the unit were thinner than gloves she had worn in her previous place of employment. She called this out to Holly, her group leader, and Holly then proceeded to investigate. It turns out that the supplier had mistakenly sent the wrong kind of gloves. Although other people had noticed that their gloves had changed, no one else had thought to call out the issue.
The problem is that OSHA requires a heavier grade of gloves for people working with chemotherapy drugs because of the potency of those drugs. If the medication gets on skin, it can be absorbed. In a clinic like this, with a number of younger women nurses who might be pregnant or might be planning to get pregnant, this could be particularly dangerous. The attentiveness shown by Susan and Holly quickly resulted in a review of the situation, determination of the root cause, and fixing the problem.
Posted by Paul Levy at 4/23/2009 11:34:00 AM