MEDNAX patient safety app effects change on a device production line

August 17, 2018 | by Cheryl Cranick
MEDNAX patient safety app effects change on a device production line

The development of a reporting culture is a central component of MEDNAX’s High Reliability Organization (HRO) program. By sharing clinical issues and concerns, our providers can learn from the challenges they face and gain the resiliency required to improve patient safety. Reporting occurs at several levels, such as within a specific facility or practice; while other reports are shared company-wide. The reporting technology — MEDNAX’s mobile Clinical Safety App — allows for a broad approach to sharing information through push notifications to clinicians for closed-loop communication. However, sometimes, incident reporting helps make real change possible not only for MEDNAX patients, but patients across the country. 

In March, a concern report was submitted by a MEDNAX-affiliated certified registered nurse anesthetist. This provider noted a white substance on the tip of multiple blunt fill needles when drawing up medication. The report was immediately acted upon by the hospital and anesthesia leadership to ensure patient safety. The MEDNAX patient safety lead at this facility reached out to the manufacturing company to share the concern with the medical product.

Just two months later, the device manufacturer responded with feedback about its quality control investigation into the product, initiated by the concern report. The manufacturer identified the substance as “epoxy splatters and drip-overs.” While the company could not say for sure the exact cause of the epoxy residue, the quality control team took MEDNAX’s concern report seriously.

The device company believes this affected batch of needles was an isolated incident; however, in its response, the device company outlined steps it plans to institute for continuous product improvement, including additional staff training and assembly line modifications. In the response letter, the device company stated its commitment to providing “safe, effective and reliable products.”

 “I believe this is evidence that our reporting culture and patient safety efforts are making a real difference,” said the MEDNAX patient safety lead. “The device company made specific quality process changes in their assembly line in response to our report.”

 Jeff Shapiro, MD, Director of the MEDNAX Anesthesia HRO Program, agrees. “Our reporting culture, which is facilitated by our Clinical Safety App, allows incident reporting to improve system components and enhance patient safety. It also demonstrates how empowering a reporting culture is in creating a proactive mindset to forestall and contain errors,” he said.  “We have created real-time incident reporting, which helps ensure we eliminate delays in responding to concerns that may affect the safety of our patients. What’s really exciting about this specific report is the ripple effect our provider made on keeping all patients safe, not just those under our team’s care. The Clinical Safety App has allowed the individual to make a powerful impact on patient safety.”

Dr. Jeff Shapiro, Director of MEDNAX HRO ProgramFor more information about MEDNAX’s HRO program, please contact Dr. Shapiro at




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