Small step towards a just culture

When David was talking about just culture on our last day at Turf Valley, and empowering every member of the team to speak up without fear, I remembered a story…

As pediatric residents we rotate in the newborn nursery, and it becomes a routine to ask the nurses to collect the babies at 5:45 AM, to start and get the blood for the routine bilirubin check and newborn screens, and sometime before 6AM, we start examining the babies. Many times I help nurses collect the babies, and explain to the new mothers what is happening with their newborn infants. I have a system I follow daily after aligning all infants in the room with big windows on the third floor: I start examining all the babies one-by-one, and go through each system, making sure I finish with the red light reflex on each one of them. When the attending arrives we discuss the patients, I ask all my questions and then complete my daily notes and discharges for the day. By then, it is 7:30AM, and the infants, with new blankets, new diapers, and often funny hairstyles, are ready to go back to their mothers’ rooms. One person: attending, resident, nurse, or other ancillary staff member should be present at all times in the room where we collect, examine, and change the babies. I enjoy talking to the new mothers, explaining what to expect from their newborn, and answering a multitude of questions regarding the feedings, signs of hunger, activities, sleeping, when to take the baby outside, when it’s safe to go to the beach, vaccinate, follow up with the pediatrician after discharge, or whatever questions a new, anxious parents might have. So, I often find myself taking the infants back to their rooms.

I’m always smiling, as I really like to get to know the members of the hospital team, so when I go to discuss plans with my patients, I know the names of every person who walks in the room and interacts with them–from the charge nurse, to the lady who brings the meals. One day, Maria, the nursing assistant was in one of the rooms, and as I walked in, she welcomed me with a big smile, telling the mother how lucky she is to have me as a doctor :). I was very happy to hear that, and at some point as I was focusing on the Mom to see if she had additional questions for me, Maria left the room, though I don’t even remember when. Once I finished with the mom, said goodbye and wished the best to the family, I left the room and found Maria outside the door. With her hand on my left shoulder she said, “Doc, I would not say this to any of your colleagues, but I really wanted to say something to you… May I please give you some advice?” For a moment, I didn’t realize what she was talking about, and felt my ears getting hot and red. I tried to smile, but I couldn’t, I was nervous and curious. She continued, “I saw you bringing the baby to the Mom in room 385, and doctor, just an advice, don’t get upset!” At this point I really felt uncomfortable, I knew I had done something wrong. “You, Doc, didn’t check the bracelet on that baby, and didn’t ask the mother for her ID band…I just wanted to tell you this because some time ago, one of our nurses got fired after she took a baby to the wrong mother, who breasted this infant…” I realized in that moment how important this step was, and even though it sounds normal to check, that was not part of my routine. I gave her a big hug and thanked her. She was the first one to tell me that, even though she was not the first one to see me taking babies to the Mother’s room. In that moment I realized how close I was to make a mistake the day before, when the room number was wrong on a baby’s bassinet and while walking in the room, I saw the Mom with another baby (her own) at the breast. The nurse, as I was walking in, confused, told me they have switched my infant’s mother to a different room, and directed me to the right place. I realize now that even when I was so close to making a mistake, I still didn’t check the bracelet… I realized what an important lesson Maria had given me…

I asked my fellow residents that same day if they check the bracelets on each baby and their moms, and all of them said “we should”, but nobody was doing it, because nobody told us at the beginning of the rotation about this step…it was Maria who changed our routine. I wonder how many mistakes we are avoiding every day by checking ID bracelets, and it is all because of Maria, who probably doesn’t even know the term “just culture”, but knows to speak up when something is not right, or when procedures are not followed. She spoke up because she knew I would appreciate it, but to make this a culture change, we have to be open.

This is a big step towards just culture, and I wanted to share this story with you, because I really hope there are many Marias out there, and they are the key team members who can be used as role models in our effort to become open-minded and honest on our way towards zero preventable harm.

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