Patient safety is important to me because health care is about treating and caring for patients in a safe environment to avoid further issues and suffering. I have been in the health care field for 4 years as a nursing tech and 10 years as a nurse. I have seen many safety issues and events over the years that caused patients harm and even death. Patients shouldn’t focus on what goes wrong during their health care journey but no patient’s experience is ever perfect. I recently had foot surgery 2 years ago and I was even impacted by a safety event. The day of surgery, in preop, the anesthetist was consenting me about my operation and realized half way through his conversation that I was the wrong patient. He confused the room numbers and didn’t check my wrist band. I was thankful that I was oriented enough to make that correction, but some patients are unable to correct miss communication or simple errors that can occur.
I have been on the fall and safety committee at three different hospitals during my nursing career. Recently in 2019, at MedStar Georgetown University Hospital, I invented and initiated a fall safety standard that went system wide to help reduce falls. I noticed during my monthly fall audits that patients were falling because the bed alarm was not properly activated, but looked like it was plugged in correctly. I found that during dayshift the nurse would have the patient up in the chair, and when returned to the bed, that alarm cords weren’t switched. I created a colored label system that could be easily seen from the door way. All staff could then identify quickly if the correct cord was properly plugged in. Now Medstar has switched to a new device by the Posey company. This device has two ports which can have the bed and chair alarm both plugged in at one time.
I am continuing to see great changes in patient safety over the decade but unfortunately humor error cannot be completely eradicated. Education plays a big role in patient safety. Standards of practice change daily and with each safety event, new ways can be learned to prevent similar future mistakes. It is up to everyone individually to continue to improve and learn from mistakes to make healthcare safer in the future.