Proactive staff help avert patient safety crisis in OR

Hydraulic fluid in barrels labeled Klenzyme’

A group of alert instrument technicians at Wake Forest University Baptist Medical Center in Winston-Salem, NC, averted disaster when they discovered that several barrels of liquid labeled "Klenzyme" turned out, in fact, to contain hydraulic fluid.

Wake Forest hospital officials say a quality improvement program that encourages employees to proactively report situations that cause them concern may have been instrumental in avoiding the potentially serious consequences.

"Certainly, there is an emphasis on employees and workers being empowered to say something isn’t right and look into it," notes spokeswoman Karen Richardson. "That’s what enabled them to catch the problem so quickly."

A greasy feel’

On Dec. 13, 2004, when two loads of surgical equipment at the facility were washed, they came out with what was described as a "greasy feel."

"Two instrument techs were running these loads and immediately said, Something’s not right here,’" Richardson says. "They looked in the barrel labeled Klenzyme; and instead of having a clear, amber color, it was a darker liquid with a greasy texture."

The techs replaced it with the correct product and reported to their supervisor to see what to do next. "It was decided to run the correct product through an empty cycle three times to clear out the lines," she reports. "Then they rewashed those instruments three more times to make sure all the residue was off."

At the time, it was thought the hospital had just gotten a bad batch, so the supplier was contacted for a refund. Later in the month, however, the supplier informed the hospital that it may have gotten some hydraulic fluid by mistake. As it turns out, the other three or four barrels already had been disposed of when the techs thought they had gotten a bad batch of cleanser.

Overcoming reluctance

Overcoming an employee’s natural reluctance to report something amiss is an ongoing process, says Ron Small, MBA, vice president for quality outcomes.

"When you start talking about a culture of excellence, obviously a lot of variables go into that," he explains. "I define culture as peoples’ behaviors — it’s not what they write about or think about, but what they do."

The current QI campaign theme is "Quality is Our Difference," Small notes. "That means it’s everybody’s responsibility every day."

Getting over reluctance to report problems requires behavior change over time, he continues. "Trust comes when they see it’s OK for them to say they have concerns," Small continues. "For example, we want our nurses, pharmacists, and so on, to say to the physicians and their colleagues, Excuse me, I have a problem,’ and to stop any such process."

At Wake Forest, it’s OK to stop a process, he adds. "We even give them phrases, like I need clarification,’ that automatically stops the process. When that occurs, there’s no question — it just stops. This fits in nicely with [Joint Commission on Accreditation of Healthcare Organizations] JCAHO requirements."

The program’s standards of behavior also address the manner in which concerns can be raised and responded to. "When you make a commitment to excellence, it’s OK to make sure you get your concerns addressed, but we will not tolerate rudeness," Small asserts. "We have outstanding clinical leadership, and they will follow up with anyone who is rude in the process."

The four C’s

If a facility is really going to improve, he says, it must begin with what he calls the Four C’s. One is "commitment of leadership." The others are:

  • Candor: You have to admit you can improve processes.
  • Courage: Have the courage to admit that, and start looking for ways to improve.
  • Comparison: Know how you stand compared to similar facilities. "We try to be in the top 10% for all measures," Small says.

He might have added "Communication," because the facility does a lot of it. "Our marketing folks put posters everywhere [for the new campaign]," Small notes.

"A lot of the clinical administration executives met people at the door and gave out buttons, which had all the [JCAHO] National Patient Safety Goals on the back," he says.

The internal newsletter Infinity contains three or four articles each month. "So far, there have been about 21 articles this year, and I and others have also made presentations about quality," Small adds.

The hospital’s core values are excellence, compassion, innovation, integrity, and collegiality, each of which has its own standards of behavior. "Culture is how you behave, not what you say," he concludes.

Need More Information?

For more information, contact:

  • Ron Small, MBA, Vice President for Quality Outcomes, Wake Forest University Baptist Medical Center, Winston-Salem, NC. Phone: (336) 713-3410. E-mail: