Two years ago, CRNA Jason Cobb’s alertness, quick thinking and willingness to speak up prevented a potential wrong-site surgery. He recently became the first recipient of a new patient safety award that was inspired by his actions that day and his demonstrated commitment to patient advocacy.
In December 2014, a patient was being prepared for knee surgery at one of Sheridan’s partner facilities in Middleburg, Florida. All the records, including the consent form the patient had signed, showed that the surgery was to be performed on his right knee. The OR team confirmed that as the correct surgical site during the routine pre-op time-out. But when 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 the patient's left knee.
Cobb quickly checked his records again to verify that the right knee was the correct one, then immediately stopped the procedure and explained his concern about the site discrepancy. The surgeon checked the X-ray again, which showed that the right knee required surgery. He immediately closed the incision and called an emergency meeting with the patient's wife and Quality and Risk Management. The surgeon explained openly what had happened and, at the patient’s wife's direction, the surgery was performed on her husband’s right knee.
Subsequently, the patient and his wife spoke with the hospital and North Florida Anesthesia Consultants (NFAC), which provides anesthesia services in the Duval/Clay County area, about the stress the family experienced because of the potential wrong-site surgery that Cobb’s alertness and actions had prevented. All the parties were eager 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 the hospital and its not-for-profit philanthropic foundation to establish an award named in honor of the patient and his wife. The award would 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 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.”
Cobb 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.
Practice manager Sarah Turpie, MBA, MSN, RN, praises Cobb’s outstanding clinical, leadership and personal qualities and says he quickly became a valued member of the group after joining NFAC in February 2014. When he applied for the group’s inaugural Chief AHP position last year when Sheridan acquired NFAC, Turpie says that during the interviews he stood out as a leader who would put his coworkers first, represent their collective voice well, and maintain the group's “unique cohesiveness.” Since Cobb became Chief AHP, she says he has taken on every challenge given to him “with utmost attention and dedication” and has gone the extra mile to solicit and implement ideas from the staff to improve their work environment.
Cobb estimates that the award ceremony was attended by 50-75 people, including the hospital’s CEO and other administrators and the philanthropic foundation committee. The ceremony began with an address by the hospital’s system vice president and chief medical & quality officer. He described the incident that led to the creation of the award and showed the patient safety video, which features this patient’s case, that is now part of the orientation for all new employees of the entire health system nationwide.
After the ceremony, Cobb, who has been in nursing for 18 years, met the couple’s son, who thanked the CRNA for what he had done for the son’s father. Cobb’s wife, an employee at the same hospital who has been in nursing for 25 years, finally had the opportunity to meet the patient and his wife, who told her, “We love Jason as much as you do.” After the ceremony, the Cobbs returned to be with another of Jason’s biggest admirers, his 12-year-old daughter, who couldn’t wait to hear all about the event and see her father’s well deserved award.