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Great Catch winners help YNHH become a high reliability organization

Congratulations to these Great Catch winners for modeling HRO safety behaviors and taking action to improve patient safety.


Kelley Kling, RN, South Pavilion OR cardiac, was recognized for practicing a questioning attitude, attention to detail and 200% accountability. While helping prep a piece of surgical equipment, Kling noticed the device did not appear to be working correctly. She quickly stopped the line and escalated her concerns to the surgeon, who assessed the situation. A new valve was obtained and was successfully sutured in place. This malfunction was escalated to the system level to ensure it does not happen again.


Amanda Adante, ambulatory care associate, Women’s Services Infusion, was recognized for practicing a questioning attitude, attention to detail and 200% accountability.  While performing an EKG during a treatment visit, she noticed that the machine’s interpretation did not fit the patient’s presentation. Adante reapplied the EKG, checked all connections and got a different interpretation. Knowing these results did not fit with the patient history and could be unlikely, she escalated her concerns. She and her counterpart nurse repeated the EKG with a different machine, which showed an appropriate interpretation. Adante contacted staff with Biomedical Engineering, who determined the machine had a malfunction requiring updated software. Adante’s use of CHAMP behaviors prevented incorrect information from being saved into the patient's chart.