‘Good Catch’: Rice Hospital employee honored with state patient safety award

WILLMAR - While reviewing a patient’s chart before admission for surgery, Nita Tieszen saw a blank space where information about the patient’s blood type should have been.
Tieszen, a registered nurse and admission coordinator at Rice Memorial Hospital, knew the patient’s surgeon always ordered this particular test, so she picked up the phone and clarified it with the doctor to make sure the test was done.
It was a lucky thing she did, because the patient began bleeding severely during surgery and ended up needing blood transfusions.
For her actions, Tieszen was honored Monday with the Minnesota Hospital Association’s quarterly Good Catch for Patient Safety award.
The award is given to hospital workers whose attention to detail, adherence to safe practices and sound clinical judgment help avoid bad outcomes in patient care.
In the case that Tieszen caught, “it would have been a mad scramble, a real opportunity for an adverse event to happen” if accurate information about the patient’s blood type hadn’t been obtained ahead of time, said Lorry Massa, president of the Minnesota Hospital Association.
For the past decade, hospitals in Minnesota have been required to publicly report certain types of adverse events each year that lead to patient harm.
The process has allowed hospitals to share information and learn a great deal about best practices that improve patient safety, Massa said.
But hospitals also can learn from - and feel good about - their good catches that prevent harm from reaching the patient, he said. “When you succeed, you need to hear about it.”
The Minnesota Hospital Association started its Good Catch award program in 2010. Hospital staff can be nominated for the award by co-workers or supervisors. A panel of judges reviews the submissions and chooses an award winner four times a year.
Quarterly winners then are in the running for the annual Minnesota Hospital Association Patient Safety Award.
Tieszen, who has been with Rice Hospital since 2002, said she was “just doing my job.”
In the case that she caught, two surgeons were scheduled to perform a double procedure on the patient but one of the procedures didn’t routinely require blood typing and matching, and the surgeon for that procedure was also the one designated to handle the pre-surgery orders.
“I’m just so thankful it had a positive outcome,” Tieszen said.
For a Rice Hospital employee to win a state Good Catch award is “a big deal,” said Wendy Ulferts, chief nursing officer.
Good catches often happen behind the scenes and go unnoticed, she said. “We only know about those events that could have happened when people report them.”
Safe patient care takes constant attention to every detail, said Mike Schramm, chief executive of Rice Hospital.
“Sometimes that sounds like it goes without saying but it’s hard work,” he said.