Congratulations Spring 2023 Award Recipient
Dani Morton, OB Surgical Technologist at University of Washington Medical Center.
Dani’s good catch and assertiveness, and UWMC’s culture of safety, prevented an unintentional error.
All nominations are submitted through this on-line form
Next nomination deadline is December 30, 2023
Did you know that seeing a problem and speaking up about it before it does harm, or as some like to call a “good catch”, is a strong indicator of a positive organizational culture of safety?
The Washington Patient Safety Coalition (WPSC) Speak-Up! Award is a statewide recognition program to celebrate individuals and teams at Washington healthcare organizations who voice their concerns to keep patients and staff safe.
When someone or a team is nominated for this award they did the right thing for patients and staff and their actions serve as a model to others.
The WPSC Speak-Up! Award is open to individuals and teams from any Washington healthcare organization from hospitals to pharmacies.
If you are interested in how speaking up and awards like this can make a difference please read Adam Novak’s article “Improving safety through speaking up: An ethical and financial imperative.” in the Journal of Health Care Risk Management, Vol 39, No. 1.
We want to thank the Michigan Health & Hospital Association Keystone Center PSO and the Virginia Hospital and Healthcare Association for their support. This program is modeled after similar awards in Michigan, Virginia, and Minnesota.
There are three 2023 Awards
Nomination due dates are:
– May 31, 2023
– September 28, 2023
– December 30, 2023
Its important to use the last question, which is a short description of the event, to elaborate on your responses to the other questions. For example: Why wouldn’t somebody else have caught this? Why would someone remain silent? What barriers to speaking up exist in the organization? What changes did the organization make?
|Organization Name||General Hospital|
|Organization Address||705 2nd, Seattle, WA 98101|
|Nominator Name||Stan Smith|
|Nominator Organizational Emailfirstname.lastname@example.org|
|Nominator Title/Position||MHA RNBN, PSO|
|Nominee Name(s)||Sarah Wright|
|Nominee Organizational Email(s)||email@example.com|
|Nominee Title/Position(s)||RN, Oncology|
|Nominee Phone||206-555-1212 X113|
|What type of adverse event or error was prevented? i.e. medication error, fall, etc.||Medication Error; Inappropriate Treatment|
|If the nominee(s) hadn’t spoken up, what is the likelihood that this could have ended as a “near miss”?||Unlikely|
|If the nominee(s) hadn’t spoken up, do you think that somebody else may have caught this?||Unlikely|
|If the nominee(s) hadn’t spoken up, what is the likelihood that the patient/resident/staff would have incurred permanent damage?||Likely|
|If the nominee(s) hadn’t spoken up, what is the likelihood that the patient/resident/staff could have died?||I’m Not Sure|
|Was the decision to speak up spontaneous or premeditated?||Spontaneous|
|Would it have been easy to have remained silent?||No|
|Did the nominee(s) encounter barriers to speaking up (such as somebody brushing off their concern)?||No|
|Was the patient, resident, family or representative informed of the of the concern?||Yes|
|Did the organization make any changes as a result of speaking up?||No|
|Please include as much anecdotal information below that you are comfortable disclosing about the event (please omit protected health information):||
This event involves a situation where an order was placed for Irradiated Packed Red Blood Cells (PRBCs) for an oncology patient, but what arrived at the bedside were non-irradiated PRBCs. Through investigation, it was found that a number of “Swiss-cheese holes” led to the wrong blood product arriving at bedside.
Thanks to RNs commitment to patient safety, her actions prevented an immunocompromised patient receiving a product that could have put them at risk for a rare but serious complication (transfusion-relatedgraft-versus-host disease). The RN identified that the PRBCs were not irradiated, through paying attention to detail (STAR: Stop Think Act Review). She spoke up for safety by contacting transfusion services to raise concern about the blood product delivered (CUS: Concern; Uncomfortable; Stop).
The patient and family was informed of the of the event and an apology was issued as well as how the organization will investigate and make changes to the process.
The end result of the RN speaking up was a new order process that was implemented throughout the health system.
All nominations will be reviewed by WPSC staff and a committee of patient safety and quality improvement leaders and patient advocates. All nominations are deidentified before going to the committee.
May 31, 2023 Award
Dani Morton, OB Surgical Technologist, University of Washington Medical Center
December 2, 2022 Award
July 8, 2022 Award
The WPSC Speak-Up! Award is open to clinical and non-clinical staff. Nominees may be individuals or teams from any Washington healthcare organization, such as hospitals, pharmacies, long term care (e.g. skilled nursing facilities & assisted living facilities), clinics and physician offices to name some examples. This award is founded on the principle of transdisciplinary teamwork; everyone has the right to be concerned and everyone has the right to speak up.
Yes, you may nominate yourself, though we will require another contact at your facility to verify the authenticity of the event.
Not at this time. This award is focused on acknowledging the efforts of healthcare staff. However, the roles of patients, residents and families may be acknowledged and part of the narrative.
You can nominate the same individual or team multiple times, but it must be for a different event. If two nominations are submitted for the same event, we will reach out to the contacts listed in the nomination forms to work with each nominator.
There will be a limit of one award finalist per organization, per period. All organizations and staff are still encouraged to nominate as many individuals as they would like, though only one nominee will move into the finalist pool per period.
Yes, though we do encourage you to submit as much information as possible, we realize that certain information is sensitive.
Nominations are for events no older than 12 months.
We would like to share your Speak-Up! story in a de-identified manner if possible, but will always respect the wishes of you and your organization. None of the details of the event within your nomination form will be published unless otherwise approved by both you and your organization.