The system works
Each month, the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety recognizes staff members who have made great catches that have prevented medical errors.
It may seem like a small thing: Because of a missed message, a surgical technician was wearing latex gloves when taking surgical instruments from their packages before a surgery.
The problem? The patient was allergic to latex, and latex from the gloves that came in contact with parts of the surgical instruments could have come in contact with the patient, potentially causing an allergic reaction.
During a briefing before the surgery, David Mozingo, M.D., a professor of surgery and anesthesiology in the College of Medicine, and a team consisting of an anesthesiologist, nurses, anesthesiology and surgery residents and a scrub technician were running through their typical safety check. The safety check ensures the team is operating on the correct patient and the correct area of the patient and reviews whether the patient has specific allergies.
When a nurse noted the patient’s latex allergy, Mozingo asked if the surgical instruments had been set up with latex-free gloves. They hadn’t. The team broke down the surgical instruments and, using latex-free gloves, opened a new set of instruments.
But Mozingo, who received a Great Catch Award for noting the discrepancy, doesn’t consider the lost message a mistake.
“I was pleased because the system worked,” Mozingo said. “That’s why we do what we do: This was just a sign that the system works.”
Mozingo does not think any single person was at fault or deserving of the Great Catch recognition.
“Patient safety is a team sport. Everyone was there at the briefing, participating and listening with their undivided attention,” Mozingo said. “There were probably eight or nine people in the room that caught this. It wasn’t just me.”
MORE Great catches
Other recent Great Catch Award recipients include: