August 6th, 2009

Quality and Safety

By ldw06

Childhood Game of 'Tag' In Boston ED Changes to 'Assassin'

On May 1, the emergency room team at Beth Israel Deaconess Medical Center in Boston agreed to a game of "Tag, You're It," primarily to improve hand washing and avoid transmitting infections, but also to add fun to a rote task. They did so in part because federal investigators were about to launch a 7-day review of the campus after of a cluster of methicillin-resistant Staphylococcus aureus infected 19 newborns and 18 mothers in another part of the hospital. Though the infections were not found in the ED, there was a concerted effort among the staff to avoid any citations stemming from heightened scrutiny, explains ED chief Richard Wolfe, MD. Complete hand-washing compliance is tough for even the most dedicated providers, Wolfe says. During a normal shift, one might wash hands 100 times, or six times for each of the 150 patients a day treated in the ED. "When we did internal observations, we could usually spot a miss within the first 10-15 minutes," Wolfe says. With "Tag," any time any of the 120-member staff noticed a provider not washing one's hands before or after patient contact, the negligent staffer's name would be posted on all dashboards of all computer monitors throughout the hospital system. However, three weeks after the game began, a few members of the staff, including nurses, physicians, and technicians, became "nervous" and asked to stop the game, Wolfe says. Some felt their jobs might be vulnerable in a time of layoffs, "although we had made it clear that this would not happen and there were no consequences," to getting tagged. They read: "Tag! So-and-so is it." The answer, he says, appears to be a variant of the game "Assassin." Employees who are tagged will just be marked out of the game, not listed on computer monitors or anywhere else.

HealthLeaders Media by Cheryl Clark, June 4, 2009

 

Tags: Industry News & Competitive Intelligence, Quality, Safety

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