The Bob & Ethel Allison Patient Safety Award was conceived in response to a potential wrong-site surgery two years ago that was prevented thanks to the alertness, quick thinking and willingness to speak up of CRNA Jason Cobb. On Tuesday, Cobb became the first recipient of the award his actions helped inspire.
In December 2014, Bob Allison was being prepared for knee surgery at St. Vincent’s Medical Center Clay County in Middleburg, Florida. All the records, including the consent form Bob had signed, showed that the surgery was to be performed on Allison’s right knee, and the OR team confirmed that as the correct surgical site during the routine pre-op time-out. But when Jason Cobb looked over the drape about two minutes into the procedure to check on how things were progressing, he noticed the surgeon was on the left side of the bed and the incision had been made on Allison’s left knee. Cobb quickly checked his records again to verify that the right knee was the correct one and then immediately stopped the procedure. He explained his concern about the site discrepancy and the surgeon checked the X-ray again, which showed the right knee required surgery. He immediately closed the incision and called an emergency meeting with Ethel Allison and the Quality and Risk Management, where he explained openly what had happened. At Mrs. Allison’s direction, the surgery was then performed on her husband’s right knee.
Subsequently, the Allisons spoke with the hospital and North Florida Anesthesia Consultants (NFAC), which provides anesthesia services for all three St. Vincent’s Medical Centers in the Duval/Clay County area, about the stress the family experienced as a result of the potential wrong-site surgery that Cobb’s alertness and actions prevented. All the parties were anxious to do something to help prevent this type of situation from happening in the future. The family and NFAC, which was acquired by Sheridan in 2016, partnered with hospital and The St. Vincent’s HealthCare Foundation to establish an award named in the Allisons’ honor to reward medical staff for making patient safety their highest priority and, as Cobb says, for “speaking up in an environment where you might feel that you are not the highest authority in the room and you might be afraid to say something when you see things that are wrong.” Cobb hopes the award, which will be presented quarterly, “will encourage others who may be afraid to speak up for fear of retaliation or of being fired – young people, new nurses, new graduates, people in other fields who are not in positions of authority at the hospital – to say something when they notice a potential issue and know that the hospital will support them and have their back.”
He is extremely modest about being the award’s inaugural recipient, saying “I don’t think I did anything special, nothing that anyone else wouldn’t have done.” But the Summary Data of Sentinel Events Reviewed by The Joint Commission suggests he’s not giving himself enough credit: Wrong-patient, wrong-site and wrong-procedures were the second most common type of sentinel event reviewed by the Joint Commission that year.