Patient Safety Bulletin
By Sue Neumann

New Online Occurrence Reporting System Went Live on September 1, 2009

On December 1, 1974 at 11:10 am an event occurred that changed the world of aviation.  TWA 514, a Boeing 727 crashed into a mountain side as it prepared to land outside Washington, DC, killing all 92 people on board.  During the accident investigation, multiple pilots spoke of near misses when they used the same landing approach.  The near misses had a common thread related to the terrain and communication issues, the same two root causes were identified as the reason for the crash.  However, the near misses were not reported because a system to report such events was not in place.  As a result, aviation now has systems to document near misses in order to prevent future disasters. 

Just as aviation implemented systems to report near misses, Woman’s  is improving its system to report near misses and occurrences.  The “Online Occurrence Reporting” system makes filing an occurrence report as easy as a click of the mouse while guiding users though completion of the report. One goal of the new system is to increase the quality and quantity of reported occurrences. Another goal will be to identify near misses, areas for systems improvement and track trends.  This information will lead to a safer environment for our patients and employees. 

Training for the online occurrence reporting system will occur the week of August 24th.  The basic user training presentation is approximately 30 minutes in duration and discusses Woman’s  occurrence reporting policy and a walk-through on how to complete a report.  Each area has identified a “super user” who will be available to assist you with completing a report if you are not able to attend a training presentation.  Watch for a flyer with the dates, times and locations of the presentations to be posted soon

 

Congratulations
The Maternal-Fetal Medicine team  was honored at the August Leadership meeting for their hard work. Thanks for all you do to help keep Woman's exceptional!
 

31 Exceptional Years
By Therese Bourgoyne

Friends and family joined Gay Montealegre on Thursday, August 6, to celebrate her retirement from Woman’s Hospital.  Gay began working at Woman’s in April of 1978, in the department that was called “2nd Floor”.  She took care of the mothers after they delivered their babies, not both mother and baby, as they do today.  

The staff in the Mother/Baby department is sure to miss Gay.  She was someone that they could always count on to be there.  

Gay will be spending her retirement doing a little traveling, visiting her daughters, and spending time with her grandchildren.

Thank you Gay for all you’ve done for the women and infants of this community for the last 31 years.  We’ll miss you!