Adult Critical Care Nurses at Beth Israel Deaconess Medical Center
January 2025
Adult Critical Care Nurses
Beth Israel Deaconess Medical Center
ICU
IHI - Institute for Healthcare Improvement
Cambridge
,
MA
United States
Nurse Executives shown:
Suzanne Joyner, DNP, RN, Associate Chief Nurse for Critical Care and West Campus Inpatient Services - Back center, in blue V-neck top
Pat Folcarelli, PhD, MA, RN, Senior Vice President for Patient Care Services and Chief Nursing Officer - - Back, fourth from right, in grey blazer and black top
Patricia Bourie, MS, RN, Associate Chief Nurse for Patient Care Services Safety, Quality, and Nursing Informatics - Back third from right, blue blazer
Suzanne Joyner, DNP, RN, Associate Chief Nurse for Critical Care and West Campus Inpatient Services - Back center, in blue V-neck top
Pat Folcarelli, PhD, MA, RN, Senior Vice President for Patient Care Services and Chief Nursing Officer - - Back, fourth from right, in grey blazer and black top
Patricia Bourie, MS, RN, Associate Chief Nurse for Patient Care Services Safety, Quality, and Nursing Informatics - Back third from right, blue blazer
The Adult Critical Care Nurses Beth Israel Deaconess Medical Center were selected as the 2025 Team recipient of the DAISY Award for Extraordinary Nurses in Patient Safety, in collaboration with the Institute for Healthcare Improvement (IHI).
The work of our ICU teams that led to an intravenous (IV) pump software recall (see details in Nurse Manager statement) was an extraordinary example of many of the core principles of patient safety. These nurses felt an acute and pressing sense of accountability when they realized that a critical piece of ICU equipment was not functioning as it should. Not content to settle for workarounds, they observed core principles of patient safety and accountability for practice, including transparent reporting and involvement of key stakeholders. While the situation was ripe for the phenomenon known as “normalization of deviance” - - when a deviant factor in the care environment is common and therefore treated as normal - - nurses in our critical care units had a shared understanding of the potential safety implications of the frequent medication delivery interruptions that were occurring due to false IV pump occlusion alarms. They appropriately used existing communication vehicles and our patient safety reporting system, which quickly made it apparent that there was a patient safety risk. By calling out this issue, they set in motion a cascade of events that led to a nationwide safety recall involving a particular IV pump.
This is an extraordinary example of commitment to excellence through the mitigation of patient safety risks. It is a demonstration of how this staff is passionate about accountability for practice and, most importantly, how they use this passion to advocate for change. The team received formal recognition from the Food and Drug Administration, which noted their “outstanding contribution in promoting patient safety with medical devices.”
*****
The actions of nurses in our organization’s ICUs provided an extraordinary example of accountability for patient safety that led to a nationwide recall. Nurses noticed that medication pumps were sounding an excess number of false occlusion alarms. These pumps were delivering highly potent vasoactive and other agents. This type of alarm shuts off the pump, interrupting the delivery of crucial medication. Because of the intentional tight communication practices across our critical care units, nurses quickly realized the problem was not isolated to individual pumps or certain units. Not content with workarounds, the nurses used our patient safety reporting system to call out the problem. Involvement of clinical engineering ensued, which led to communication with the pump manufacturer. It was soon discovered that the pumps were sounding false occlusion alarms due to an issue related to a recent software upgrade. Moreover, the investigation revealed that pumps by the same manufacturer deployed across the nation could be having the same issue. This led to a nationwide Class 1 recall, defined as a situation in which there is a “reasonable probability” that patient exposure to a particular product “will cause serious adverse health consequences or death.”
The work of our ICU teams that led to an intravenous (IV) pump software recall (see details in Nurse Manager statement) was an extraordinary example of many of the core principles of patient safety. These nurses felt an acute and pressing sense of accountability when they realized that a critical piece of ICU equipment was not functioning as it should. Not content to settle for workarounds, they observed core principles of patient safety and accountability for practice, including transparent reporting and involvement of key stakeholders. While the situation was ripe for the phenomenon known as “normalization of deviance” - - when a deviant factor in the care environment is common and therefore treated as normal - - nurses in our critical care units had a shared understanding of the potential safety implications of the frequent medication delivery interruptions that were occurring due to false IV pump occlusion alarms. They appropriately used existing communication vehicles and our patient safety reporting system, which quickly made it apparent that there was a patient safety risk. By calling out this issue, they set in motion a cascade of events that led to a nationwide safety recall involving a particular IV pump.
This is an extraordinary example of commitment to excellence through the mitigation of patient safety risks. It is a demonstration of how this staff is passionate about accountability for practice and, most importantly, how they use this passion to advocate for change. The team received formal recognition from the Food and Drug Administration, which noted their “outstanding contribution in promoting patient safety with medical devices.”
*****
The actions of nurses in our organization’s ICUs provided an extraordinary example of accountability for patient safety that led to a nationwide recall. Nurses noticed that medication pumps were sounding an excess number of false occlusion alarms. These pumps were delivering highly potent vasoactive and other agents. This type of alarm shuts off the pump, interrupting the delivery of crucial medication. Because of the intentional tight communication practices across our critical care units, nurses quickly realized the problem was not isolated to individual pumps or certain units. Not content with workarounds, the nurses used our patient safety reporting system to call out the problem. Involvement of clinical engineering ensued, which led to communication with the pump manufacturer. It was soon discovered that the pumps were sounding false occlusion alarms due to an issue related to a recent software upgrade. Moreover, the investigation revealed that pumps by the same manufacturer deployed across the nation could be having the same issue. This led to a nationwide Class 1 recall, defined as a situation in which there is a “reasonable probability” that patient exposure to a particular product “will cause serious adverse health consequences or death.”