Maggie Yeh, RN (not pictured), and Kristen Ruge, RN, Bridgeport Hospital Emergency Department (ED), won the Great Catch Award for their attention to detail and questioning attitude. A patient in the ED who was waiting for an intensive care unit bed received intravenous potassium for a low serum potassium level. The patient was retested and found to have a high serum potassium level. The ICU team ordered a hyperkalemia (high potassium) protocol. Yeh and Ruge reviewed the lab results and thought they seemed too high. They escalated their concerns to the pharmacist to investigate the possibility of inaccurate serum potassium results. When the pharmacist validated their concerns, Yeh and Ruge escalated the issue to the ICU attending physician, who ordered the serum potassium level test to be repeated. It showed a normal level and the hyperkalemia protocol orders were discontinued, preventing a potential serious safety event.
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