Friday, June 26, 2020

A Great Example of GBMC as a Learning Organization

I was on-call this weekend, so on Sunday, Father’s Day, I did Lean Daily Management. As I was driving in, I was lamenting the fact that I would not be running in the Father’s Day 5K with hundreds of others to raise money for our NICU, and I was feeling a little down.

On the walk, when I arrived at the Pharmacy board, I was greeted by Perry Shafner, the Lead Clinical Pharmacist. Perry presented the Board and he told me of the previous day’s performance with missing medications on Unit 46. Readers of the blog know the Pharmacy is among our highest performers in the use of 5-why problem solving. For many years, the Pharmacy has investigated missing medications in real time, Monday through Friday, during the day. After hours and on the weekend, however, they are not staffed to send someone to the unit to ask the questions and “see” the work in process. Perry told me that the previous day, FIVE medications were reported as missing on Unit 46 and they were all on the same patient.

He went on to tell me that upon hearing of the missing medications the previous day, our pharmacist and his colleague, Michele Sharkey, got the call and wondered “how could this have happened?” Michele checked the delivery report and it showed that the medications had been sent through the tube system to Unit 46. Even though it was the weekend, Michele knew that the best way to get to the cause of the problem was not to wait until Monday and have someone else try to figure it out, but instead, go to the Unit and investigate while the episode was still fresh in people’s minds.

Michele arrived on Unit 46 and found that the patient had been sent there from another unit earlier in the day. The Pharmacy realized this and sent the medication to the new unit, but the document that accompanied the medication still had the patient’s previous location. Another staff member dutifully sent the medication to the old unit, believing that they were doing the right thing. So, the immediate cause of the error was putting the document with the old location in the tube that was sent correctly to Unit 46. Having gotten to the bottom of the problem, Michele and the Pharmacy team are changing the standard work to assure that the accompanying document shows the correct location.

It is silly to believe that mistakes will never happen in a large, complex system. It is exciting to see how GBMC has become a learning organization that delights in finding the cause of a problem and in using its core competency, redesigning care, to make things better! Because of Michele’s curiosity and her learning in real time, the Pharmacy achieved our Four Aims Recognition Award

Thank you!!
So, I went home much happier and I ran a 5K on my own, and I want to thank everyone else who participated in our Virtual Father’s Day 5K & 1 Mile Fun Walk to benefit our Neonatal Intensive Care Unit (NICU).

In response to the COVID-19 pandemic, we created a VIRTUAL version of this annual event. Despite this change, we had approximately 450 participants, who helped us raise more than $55,000 to help our NICU continue providing high-quality care with the best technology.

Every day, moms and dads turn to GBMC’s highly trained healthcare professionals to care for their sick or premature babies because we provide the same care that we would want for our own loved ones. I want to thank our neonatologists, nurses, advanced practitioners, technicians, and others who dedicate their lives to the health of babies. I am grateful for your commitment to our NICU, even through the COVID-19 pandemic.


  1. Thank you GBMC for the continued updates with Covid-19 and all of the positive events. We are still moving forward with life and co-workers are amazingly proactive with this process. Thank you amazing doctors and nurses for your incredible commitment. So many moments in life where you just want to jump in someone else's shoes and provide respite. I am in awe of the strength it takes to fill those shoes.

    1. Thanks for your insightful comments, Anonymous.


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