The patient was prepped, the instruments were in place, and the entire OR team was ready to begin. Following the script that hangs in every operating room, Marie Discher, the circulating nurse in the OR, started the Time Out, a process completed before every procedure to make sure that the team is operating on the correct patient, on the correct side, and is performing the correct procedure. “Time out procedure,” she said, bringing the entire team to a stop, and all eyes to her. She called on the anesthesiologist to state the patient’s name and date of birth by double checking the ID wrist band. Having just checked the band before the patient was brought to the operating room, the anesthesiologist read the information off the patient’s paper records. But, Marie insisted that the actual band be checked, and explained the importance of following the procedure. Even though the anesthesiologist had been at the patient’s side since the ID was checked in the holding area, Marie insisted that the band itself be checked, as the Time Out procedure is specifically designed to compensate for human error, and should be done exactly the same way, each and every time.

Marie received PPMC’s Patient Safety Hero award because she took a stand in the name of patient safety. Marie spoke up as an equal member of the OR team, and challenged her colleague to think about a safety behavior differently. Marie and her colleague worked through the issue and put patient safety first. The anesthesiologist said she deserved commendation because she promoted a basic safety behavior that makes our patient care more reliable. Both Marie and the anesthesiologist deserve our recognition for their contribution to improving our culture of safety at PPMC.

It is important to check the actual wrist band to confirm a patient’s identity because if we don’t, we cannot be 100 percent sure that we brought the correct person into the operating room. Many hospitals have performed surgery on the wrong person because they accidentally wheeled the wrong patient into a room. Taking a few seconds to confirm that you have the correct person, the correct side, and are performing the correct procedure right before you start protects us all. Marie received a framed certificate and an iPod Touch as tokens of appreciation.

Congratulations Marie!

Do you know a Patient Safety Hero?

The new Patient Safety Hero award will be given quarterly. Nomination forms are available on your units, in the CEQI department on the second floor of the Mutch building and on the PPMC intranet. PPMC’s Patient Safety Committee will review the nominations each quarter and choose a winner. Submit completed forms to Lisa Glowacki in the CEQI department: lisa.glowacki@uphs.upenn.edu