Great Catch winners help YNHH become a high reliability organization

Congratulations to the October 2016 Great Catch winners for modeling HRO safety behaviors and taking action to improve patient safety. To engage YNHH's growing ambulatory/outpatient departments statewide and recognize their staff's contributions to patient safety, the monthly Great Catch award is now given to an inpatient and an outpatient location.

Outpatient/Ambulatory

Carla Brotherton, interventional radiology technologist; Steve Harper, RN; and interventional radiologist Eric Reiner, DO, Saint Raphael Campus Heart and Vascular Center procedure area; and Brian Coutermarsh, interventional radiology technologist, York Street Campus HVC, were recognized for preventing two wrong-site surgeries. When a patient arrived at the SRC interventional radiology (IR) lab, Brotherton and Harper practiced a questioning attitude with attention to detail when they noticed the procedure order did not specify a site on the patient. They escalated their concerns to Dr. Reiner, who cross-checked with the referring provider and learned the patient was scheduled for surgery the next day, and the IR procedure should be done on the opposite side to avoid the surgical site. This Great Catch was shared at the next IR staff meeting and Coutermarsh applied lessons learned to a York Street Campus patient admitted to the IR without a specified site location, preventing another wrong-site surgery.

Inpatient

Lisa Crowther, APRN, Heart and Vascular Center Advanced Heart Failure program, was jointly recognized with Kathleen Gerolami and Maria Stavropoulos, Yale School of Medicine, for practicing questioning attitudes, attention to detail and mentoring with 200% accountability. Two YNHH patients had been identified and matched by the New England Organ Bank – one as donor and the other as recipient – for a heart transplant. The patients needed further testing for compatibility that was performed through Yale School of Medicine. Gerolami, YSM clinical technologist, noted that some test results did not match. She escalated her concerns to Stavropoulos, who notified transplant coordinator Crowther at YNHH. Crowther contacted the organ bank, which validated and verified the team's concerns and agreed the organ match was incorrect. The organ was ultimately successfully transplanted to another YNHH patient.