A Very Personal Story of Patient Safety

Andy Smith

When our third son was born moderately jaundiced in 2001, we didn’t panic. Parenting two other boys had effectively sanded the sharp edges of our internal “freak-out” system. But still, my wife and I spent three nerve-wracking days and nights in the NICU, hovering near our son as he received the light therapy that would lower his elevated bilirubin levels.

The hard-working team of nurses shuffled in and out, making adjustments, checking vitals, and quietly nodding assurances to anxious parents like us. Now, I work with healthcare organizations, and while this doesn’t afford me any kind of special treatment or even insider perspective (I work with the IT teams, primarily), I was taken aback when one nurse entered, took my son’s vitals and promptly wrote this “vital information” on her hand. A computer—presumably linked to the organization’s electronic health record—sat on a cart nearby, but instead of entering the vitals directly into the EHR, the nurse reported the information to us, the concerned parents, and left the room. I’m glad she’d taken the time to share the information with us, because shortly thereafter, the nurse came back in and asked us if we could recall one of the numbers… It seems her “hand chart” had gotten smudged.

As you can imagine, this situation was disconcerting on a number of levels. Foremost, our confidence in the hospital’s ability to deliver the best possible care to our son had taken a real blow. From a professional standpoint, I have dedicated my career to improving patient care by enabling healthcare organizations like this one to effectively implement—and by that I mean effectively utilize—technologies like the EHR. It doesn’t do anyone any good to implement a system that clinicians aren’t going to use. I reported the incident to the Chief Nursing Officer, not because I wanted to get the nurse in trouble (I wouldn’t give her name), but because this was a real patient safety issue and exactly the type of thing my organization works hard to prevent. 

In the end, my son was fine and we got to take him home. No one lost their job and eventually my company was hired by the hospital to help them implement their next generation EHR.

You might call it a happy ending. The reality, though, is that the issue of patient safety is an ongoing one, and there’s still a lot of work to be done. Which is why I’m proud to be a part of an organization with a mission to create a positive impact by helping healthcare providers improve patient safety and deliver the best care to the communities they serve.