Kimberly (Kim) Saunders, a medical assistant at Cooper’s Moorestown Campus, is the recipient of the Q1 Good Catch Award. She demonstrated exemplary use of High Reliability Organization (HRO) Behaviors and Error Prevention Tools—specifically the HRO Safety Behavior of Staying on Task and the STAR Tool (Stop, Think, Act, Review)—to prevent an unsterile procedure that could have resulted in potential patient harm.
During a procedure in the gynecologic oncology office, Kim was assisting a provider when she opened a packaged speculum to hand over. Following STAR protocol, she STOPPED to inspect the device and noticed what appeared to be bioburden—specifically, dried blood—on the instrument.
With swift and thoughtful action, Kim applied critical THINKING and recognized the contaminated device posed a risk to the patient. She ACTED discreetly by setting the instrument aside in a secure location, away from the patient and provider, thereby protecting the safety and integrity of the clinical experience. She then removed her gloves, washed her hands, donned clean gloves, and opened a new sterile device to continue the procedure.
Afterward, Kimberly REVIEWED the incident with the office manager, who consulted the provider and submitted a report to Risk Management. An EARS event was submitted, and the situation was discussed during the next day’s Safety Huddle.
This Good Catch powerfully reinforces the importance of staying on task and using the STAR tool (Stop, Think, Act, Review) to ensure patient safety. Had Kimberly not leveraged STAR, the patient may have been exposed to harm. By consistently applying our error prevention tools, we support a culture of safety and uphold the highest standards of patient care.
