LearningBoards Maternity

Dawn Goffredo, director of Maternal Child Health (MCH) shared,

“As an HRO, the safety of our patients and one another, is placed at the center of all we do; it requires a sustained effort from each of us, every day, all day. By working together and putting our HRO tools, tones and behaviors into practice, we continue to further our momentum in attaining our health system’s goals of achieving zero harm and eliminating preventable harm. One of our HRO leadership tools we have is our Learning Boards. The Learning Board is a great tool for staff to see their concerns work through the process. As I have staff across the system, and we continue to grow as an organization, it is even more important to be sure our staff hear a consistent message. The Learning Board, physical or virtual, is a great tool for leadership and staff to ensure communications are relayed reliably through the department.”

A recent item that landed in the Solved (green) section of the Learning Board for MCH was titled “Safe Sleep of Babies”. This sticky note was added in response to recent baby fall events on MCH.

One of the action items from the recent events was to provide education across the system to all MCH staff at department meetings and in daily unit huddles to increase awareness of Safe Sleep for newborns. Our talented and engaged frontline maternity staff came up with the great idea of adding a new component to our Great Catch Award program to help increase awareness of safe sleep for newborns and to empower all team members, no matter which department they work in, to Speak Up for Safety if they see a mother or caregiver sleeping unsafely with a baby.

It took collaboration between our Newborn Fall Team, Quality & Patient Safety, Risk Management and Marketing to fully implement this added component to our Great Catch Award program. This added component will recognize individuals who Speak Up for Safety to ensure safe sleep of babies, thus preventing harm.

“I always say, we must Speak up for Safety because it takes us all to prevent newborn falls.”

Great Catch Award Safe Sleep of Babies

This award recognizes individuals who Speak Up for Safety to ensure safe sleep of babies, thus preventing harm.

Christina (Tina) Fox, R.N., Maternity, Mullica Hill

In response to recent baby fall events on Maternal Child Health (MCH) and to increase awareness of Safe Sleep for newborns, our nurse educators provided education to all MCH staff across the system during department meetings and in daily unit huddles. We apply STAR (Stop-Think-Act-Review) in everyday situations, but especially to prevent harm in high-risk situations. Christina (Tina) Fox, R.N., was working night shift on Mother Baby in Mullica Hill when she went to check on one of her patients. Paying Attention to Detail, Tina found the mother sleeping with her baby.

Tina immediately took a STAR Moment to:

• STOP- Tina paused when she saw the mother and newborn sleeping unsafely.

• THINK- Tina thought about the risks of unsafe sleeping and her knowledge of recent events on the unit.

• ACT- Tina woke the mother, provided education about safe sleep, and asked the mother if she could take the baby to allow the mother more time to sleep.

• REVIEW- Tina ensured risks to the baby were mitigated, shared the situation with her manager and shared the situation with her unit for awareness and shared learning.

Had Tina not taken a STAR Moment to wake the mother and ensure Safe Sleep of the baby, the baby could have been harmed – and the mother would likely blame herself. This is why we must Pay Attention to Detail using our High Reliability tool STAR (Stop-Think-Act-Review) to reinforce our best practice Safe Sleep Program.

Speak Up for Safety Great Catch of the Month

Joe O’Brien & Chris Montemore, Outpatient Behavioral Health, Bridgeton

Joe O’Brien, manager of outpatient behavioral health, saw an article in the local media where he recognized a missing person as one of Inspira’s clients (patient). Joe took a STAR Moment and contacted the client’s therapist, Chris Montemore. Chris reported that the client had voluntarily put his therapy on hold due to an insurance issue. Out of concern, Chris reached out to the client who provided an update on his location, and shared he was safe.