Green Bay nurse earns national HeRO award

Ariel Wenstadt, a licensed practical nurse, will receive a national High Reliability Organization HeRO award for her actions last fall that led to a Food and Drug Administration MedWatch report.

Wenstadt was preparing to give two vaccines to a Veteran — one for flu and one for respiratory syncytial virus (RSV). While the flu vaccine comes in an already-prepared syringe, the RSV vaccine requires the powdered RSV medication to be mixed with sterile water. The powder comes in a vial, and there is an adapter used to inject the sterile water into the vial.

As she prepared the RSV vaccine, she placed the adapter on the vial, attached the syringe and injected the mixing solution into the vial. After mixing the medication, she withdrew the vaccine and prepared to give the shots to the Veteran.

Before doing so, she checked the syringes and realized she had mistakenly injected the flu vaccine into the RSV vial instead of the sterile water. She notified Pharmacy officials, giving them the tainted vaccines and obtaining new ones. She then drew up the vaccines correctly and administered them to the Veteran.

In reflecting on what went wrong, Wenstadt noticed that the RSV syringe and the flu syringe looked almost identical. Concerned that others could make the same mistake, she and Pharmacy submitted a Joint Patient Safety Report, and Pharmacy sent an email making the clinic aware of the look-alike.

Her report was shared with the HRO team and throughout the medical center to build awareness before it ultimately went up the chain to the national level.

It led to a Food and Drug Administration MedWatch report for “sound-alike, look-alike medication,” according to Lindsey Ladell, HRO program manager for the Milwaukee VA.

She said the FDA can pressure manufacturers to make a change to the materials because “It’s setting up our health care workers to make a mistake,” she said.

Reporting a mistake

While making honest mistakes is part of being human, the important step that led to Wenstadt’s award is that she reported it, Ladell said.

“She had the courage to report it on herself,” she said, noting that part of HRO is “promoting a culture where we can share mistakes and learn from them. By her having the courage to share this, the whole organization learned — not only Milwaukee, but to the VISN level, national level and the FDA.

“This allowed for widespread learning, and it’s what stood out to us. It takes a lot of courage to do that.”

Ladell said many people, in a similar situation, wouldn’t report their own mistakes. And that’s problematic, she said.

“There’s lots of literature on how under-reported safety events are,” she said, noting that people may be embarrassed or are strapped for time. “(When that happens), we miss out on a huge opportunity to learn and improve.”

Wenstadt agreed that being honored for an error comes with mixed emotions.

“It was a mistake, but I caught it,” she said. “But it’s good because it’s bringing awareness to other people so that the mistake doesn’t happen again. So I’m glad about that. I didn’t think this would go national, but it’s nice to be recognized.”

But Ladell said Wenstadt deserves the recognition.

“This is a big deal,” she said. “It’s a real testament to why it’s so incredibly important to report, because you never know the magnitude of the ripples across health care.”

Milwaukee’s third HeRO award

Before earning a national HeRO award, a recipient must be nominated at the local level, then win at the VISN level before winning again at the national level. 

Awards are given each quarter in five categories — two for individuals (clinical and non-clinical) and three for teams. Wenstadt’s award is for clinical individual.

This is the Milwaukee VA’s third national HeRO award in the past two years. Registered Nurse Jeremy Sauld won a clinical individual award in 2022 for catching a defective syringe, and Registered Nurse Meghan Lorbiecki and Simulation Program Manager Tina Smith won in 2023 for their innovative work in teaching new alcohol withdrawal treatment protocols.

“Milwaukee has the best people — people who are committed to our mission, to high reliability and to keeping our patients safe,” Ladell said. “So to be recognized at the highest level is validating.”