Never overlooking a step
Joey Straw, a registered nurse with acute care at Nashville VA Medical Center, went about his rounds like any other day – unaware how vital he would be. He stepped into his next patient’s room and began his evaluation.
His patient was recovering from a chronic illness and required extensive care in an isolation room. He was attached to a feeding tube and on dialysis to support the bodily functions of the struggling Veteran. Between the tubes and the ailment, the Veteran was unable to speak for himself – nor alert Straw if there was an issue.
Each motion Straw performed was one of muscle memory performed hundreds of times in his 27 years of nursing. They were steps that could be easily overlooked if he wasn’t paying attention. But that is not the kind of nurse Straw is – in fact, it’s his attention to detail that saved this Veteran’s life.
During his observation, Straw noticed the Veteran’s feeding tube was caught on the dressing of the dialysis catheter located on the side of his neck.
“I was worried that the feeding tube was going to pull at the dressing and dislodge the catheter in his neck and he was going to bleed heavily from that,” Straw said. “As I was redressing and moving the tube to the other side, so [the tubes] were separate on either side of the patient, I noticed a small drop of blood.”
The potential for blood is not uncommon for a new patient on dialysis, said Straw. It was the bright red color that raised flags in his mind. The bright red color meant the blood was fresh.
Drip. Drip. Drip. He watched as blood began to fall at a faster rate. Straw immediately placed direct pressure on the wound as he fought to stop the quickly pooling blood.
“I used my voice device to call for help. The charge nurses brought some dressings in for me, and then I instantly called dialysis and told them that I had a situation here,” Straw said.
Several nurses from dialysis responded to the emergency. Assessing the issue, the nurses quickly identified a slice in the tubing.
“To this day, I do not know why it wasn’t bleeding prior to my check,” Straw said.
The medical personnel quickly controlled the bleeding, and then a medicine team was called in to assist. Urgent arrangements were made for interventional radiology to exchange the dialysis access. From these actions, the Veteran’s condition was stabilized, and he was able to recover.
The speed and efficiency of the team prevented the Veteran from losing too much blood. For Straw, he feels lucky he was there to perform the check.
“If I didn’t see the blood … The next time I came in the room, he probably would have lost a lot of blood and probably not have survived. I just feel like I was kind of lucky that I saw it when I did and then I just took action like I thought I should,” Straw said.
Straw’s actions earned him a Great Catch Award presented by Daniel Dücker, VA Tennessee Valley Healthcare System (TVHS) Executive Director. The award, part of TVHS’ Quality and Patient Safety program, recognizes individuals who stop the line to maintain patient safety. In fiscal year 2024, TVHS recognized 26 recipients with great catch awards for going above and beyond to report close calls and near misses to provide the best care to Veterans.
To Straw, who has worked at TVHS for two years, this kind of recognition is key to appreciating the kind of hard work and dedication which happens every day at Nashville and other TVHS locations.
“I think that it's a great thing. I think it's important to recognize staff because there are a lot of people who really go out of their way to help Veterans. They save lives, and they do not get any kind of recognition. They clock out, they go home, and do it all over again the next day.
“I think it's important to recognize the nurses and staff for when they do something above and beyond for their work in providing a good outcome or preventing a bad one,” Straw said.
To nominate a peer or staff member for a Great Catch Award, email TVHPatientSafety@va.gov.