When Pamela Brotherton-Sedano, RN, MS, first heard the story of a medical error that led to the death of an 18-month-old in Maryland, she experienced intense sadness mixed with a sense of urgency. She felt desperate to make sure something like this would never happen at her hospital, O’Connor Hospital in San José, Calif.
She had just watched a video clip about the Josie King story in preparation for a new employee orientation. The purpose of the clip was to remind new employees of the importance of patient safety. King had been in the hospital for second-degree burns after climbing into a hot bath. Her recovery had been smooth, and she was scheduled to be discharged soon. But then a combination of dehydration and a narcotics administration error led to King’s unexpected death at The Johns Hopkins Hospital in 2001.
Brotherton-Sedano, vice president of patient safety at O’Connor, was so compelled by this story that she decided to do something about it. She wanted to find a way for patients and their family members at O’Connor to call for a medical team immediately in the event of an emergency.
Condition HPamela Brotherton-Sedano, RN, suggested that O’Connor Hospital implement Condition H, which allows family members or patients to call a rapid response number if they believe an emergency is not receiving adequate attention.
Brotherton-Sedano had heard about a hospital in Pennsylvania that had worked with Josie King’s mother, Sorrel King, to implement a new system called Condition H (Help). In this system, family members or patients have the ability to call a rapid response number if they believe an emergency is not receiving adequate attention.
This number can be used in situations such as when a patient has a sudden onset of chest pain, there is confusion about a patient’s care plan, or a patient falls and a family member needs immediate help. If a patient uses the number for a non-emergency situation, such as a complaint about a meal or a desire for more pain medication, the operator calls the charge nurse or house supervisor, who responds to the patient immediately.
In Josie King’s case, Sorrel King wished she had been able to call a rapid response team to clarify the care plan for her daughter. Sorrel questioned a nurse who walked over with a syringe of methadone. She told the nurse there had been an order for no narcotics, but the nurse said the orders had been changed. The 18-month-old’s heart stopped beating shortly after the methadone was administered.
Brotherton-Sedano was also motivated to implement Condition H because when she was a new nurse two decades ago, she experienced firsthand the frightening realization that she made a medication error. A nurse on an earlier shift had incorrectly heard the dose for a sleeping medication. Brotherton-Sedano was caring for the patient, a 25-year-old single mother, during the following shift and did not catch the error on the written order. She gave her patient 10 times what she needed. During the change of shift, another nurse caught the mistake. Brotherton-Sedano was gripped with fear as she sat by the patient’s bedside throughout the night, watching for signs of a problem. Luckily the patient didn’t experience any adverse effects.
When Brotherton-Sedano heard about the Condition H program, she talked to the hospital’s CEO about her desire to implement the new system. The CEO agreed. Then she presented the idea to the hospital’s board members, who were supportive as well.
In July 2008, the hospital was ready to launch the program. Each patient’s room includes a poster explaining Condition H in English, Vietnamese, and Spanish. Patients or their family members can call the operator at 555, the same rapid response number used by hospital staff, and the operator can then page the rapid response team (RRT). Each patient’s phone also has a sticker listing Condition H/Emergency/Dial 555. Additionally, the hospital chaplains explain the program and provide a brochure when they visit each new admission.
Preventing a Tragedy
Since the program was implemented in July, Condition H has been called 28 times. Only two of the calls have been true emergencies in which the RRT was paged, but Brotherton-Sedano anticipated this.
Even if we only had one call that was a true emergency, that is one life that could be saved, she says. Things can change so quickly with a patient, and patients know themselves best.
In one case, the operator paged the RRT when a patient who was out of breath called asking for a physician. In the other case, a female patient with diabetes called 555 when she felt her blood sugar was too low and she wanted a rapid response from a medical team. Most non-urgent Condition H calls are patients who want more pain control or are waiting for a response from the physician.
After each Condition H call, an assistant nurse manager or the hospital’s service excellence manager follows up with the patient. So far patients say they have been happy their concerns have been addressed quickly when they called 555, says Jacquie Odelson, manager of service excellence.
For Brotherton-Sedano, this response is exactly what she is aiming for.
The most rewarding thing for me is that I know we are doing the right thing for our patients, she says. They have an avenue to speak up if they are afraid, and I think that is important. We want to prevent the Josie King stories from happening at O’Connor.