living with a stranger: a story of being switched at birth

Running head: LIVING WITH A STRANGER 1

Living With a Stranger: A Story of Being Switched at Birth

Alyssa Cardinal, Blake Hufford, Jaime Morga, Sai Nguyen

California State University, Stanislaus

May 12, 2015

LIVING WITH A STRANGER 2

Living With a Stranger: A Story of Being Switched at Birth

Mason Michael, a fifteen-year-old high school student, was performing a biology

laboratory assignment when he discovered his AB blood type was incompatible with his type A

parents. Genetic testing expeditiously confirmed that he was not the biological son of Megan and

Matthew Michael. How did this nightmare happen? How had his family lived with a stranger for

15 years? A revelation would soon prove that Mason Michael was switched at birth, in the midst

of a sentinel event at St. Petersburg Medical Center in Merced, California. The undermining of

the seriousness related to lateral violence among nursing staff leads to significant, and

possibly life altering errors. These preventable mistakes result in sentinel events, which

require the attention of hospital administrators, under direct guidance of The Joint

Commission.

Sentinel Event

A sentinel event is any type of unforeseen event resulting in the demise of, or large-scale

perpetual loss of function for a patient that is unrelated to their anticipated course of illness

(“Joint Commission’s,” 1998). Another type of sentinel event, the one presented in this case, is

the discharge of an infant to the wrong family. Although this experience did not result in the

death of the child or a loss of function, the Joint Commission considers it a reviewable adverse

outcome (“Joint Commission’s,” 1998).

The term sentinel is used because these events serve as warnings and alerts that are issued

by The Joint Commission (“Joint Commission’s,” 1998). Adverse events that take place in the

hospital setting are reported to The Joint Commission and investigated with the aim of improving

patient care, treatment, and services. The goal is to prevent future occurrences and to focus

attention on understanding the causes of the event. The Joint Commission also focuses on


changing systems, and processes to reduce the likelihood of future occurrences. They increase

knowledge about sentinel events and maintain the public’s confidence in them as the accrediting

organization (“Joint Commission’s,” 1998).

Sentinel events can arise from multiple causes. In the case of 15-year-old Mason

Michael, incivility played a major role. Incivility in nursing, consists of a lack of regard for

others, violation of workplace norms, disrespectful interpersonal communication, and disruptive

behaviors that hinder positive patient outcomes (McNamara, 2012). When nurses fail to partake

in the productive culture of safety, sentinel events can occur. This is exactly what happened

when Janet Jackson sent Mason Michael home with strangers (McNamara, 2012).

Incivility and the Culture of Safety

Ecstatic to finally meet their sweet baby boy, Matthew and Megan Michael rushed to the

birthing center at St. Petersburg Medical Center. Upon arrival, a Caucasian nurse with a bright

smile greeted the couple. Her name was Janet Jackson, and she was the nurse who would help

them through the most magical moment of their lives, the delivery of their first child.

Janet completed Megan’s admission interview, preliminary assessment, assisted her into

a gown, and comfortably placed her on the monitors. Megan was already dilated to four

centimeters and labor was progressing as smoothly as one could hope. Within hours, an angelic

baby boy with big grey eyes made his way into the arms of Dr. Rocha. Mason was perfectly

healthy and ready to snuggle with his mother for the first time. The two bonded for several hours

before Mason was taken to the nursery for a procedural check-up by the unit’s pediatrician. He

never returned.

On the day of Mason’s delivery, the nursery was extremely busy. The two nurses, who

were responsible for the 18 newborns, had their hands full with assessing, monitoring, and


feeding. The primary nurse of the two, Giselle, asked Janet to assist her briefly with feeding, in

order to return the newborns to their mothers promptly. Janet Jackson verbally agreed; however,

her nonverbal cues communicated something entirely different.

Janet and Giselle had a longstanding history of lateral violence, stemming from the day

Janet was hired on the unit. Giselle displayed behaviors of lateral violence that included bullying,

verbal abuse, and lack of respect toward Janet in regards to personal communication. Other staff

on the unit assumed the poor conduct was due to Janet having a Bachelor’s degree, while Giselle

held only an Associate’s degree. Regardless, the behavior exhibited by Giselle was unnecessary

and created a potential for a sentinel event.

Simple differences, such as what type of degree a registered nurse holds, can lead to

lateral violence and intimidation. There are certain types of disruptive behaviors that can lead to

medical errors, decrease patient satisfaction, and also lead to adverse outcomes. These behaviors

of incivility, bullying, and horizontal/lateral violence lead to ethical issues in the workplace,

similar to Mason Michael’s event (Lachman, 2015). Safeguards should be in place to prevent the

reviewable adverse outcomes. Along with having an established standard of conduct for nurses

to prevent disruptive behaviors, policies such as how a newborn is properly identified, how to

transport them, and providing a safe environment should be in place (Shogan, 2002).

While Janet was feeding the two babies in her pod, Mason Michael and Benjamin Alley,

Giselle approached her. Giselle appeared to be micromanaging the tasks she delegated to Janet,

and insisted on doing her own assessment of Mason and Benjamin, as if Janet was incompetent.

Upon finishing, she demanded that Janet remove and replace the newborns’ leg bands. She

contended that they were too tight and would interfere with circulation. Janet did not feel

comfortable with the bold request, knowing it was against policy, but she was intimidated and


did not want to be bullied further. Despite her instincts and against better judgment, Janet clipped

the armbands. A secondary nurse retrieved two new leg bands from the unit clerk and delivered

them to Janet, who was still anxious and unsettled from the encounter she had with Giselle in the

preceding moments. Nurse Jackson placed the leg bands snuggly around the infants’ tiny ankles

and wheeled them back to their mothers. Mason Michael was now in the arms of Courtney and

Domenic Alley, while baby Benjamin Alley was in the arms of Matthew and Megan Michael.

Root Cause Analysis

When an organization reports a sentinel event to The Joint Commission, they are also

responsible for disclosing the findings of their root cause analysis (Lambton & Mahlmeister,

2010). A root cause analysis is a retrospective analytical method, used to meticulously look for

factors that may have contributed to the adverse outcome of the event. A key component to

conducting the root cause analysis is to focus on the failure of complex systems, rather than

focusing on the failure of an individual within the system. The main goal of this process is to

identify and uncover hidden factors that need correction (Lambton & Mahlmeister, 2010).

The framework for conducting a root cause analysis is typically outlined in a protocol

within the hospital (“Agency for Healthcare,” n.d.). There is a universal standard flow of steps

that may vary slightly from one system to the next, but customarily includes data collection,

event reconstruction, participant interviews, and record reviews. All of these steps are used to

piece together the sentinel event and locate the broken link. Once the errors have been identified,

the institution can begin the process of implementing change, in order to prevent future sentinel

events involving patients (“Agency for Healthcare,” n.d.).

Environment


Upon scrupulous examination of the sentinel event, it was determined that multiple

components played a role in the swapping of the newborns. The unstable environment, however,

had one of the greatest impacts on the outcome of the situation. Lateral violence and personal

discrepancies contributed to the hostile, unsafe work environment. Though unfortunate, these

risk factors for error are extremely common in the acute care setting. According to the results

from the 2008 National Survey of Registered Nurses, 18% of nurses reported sexual harassment

and/or a hostile work environment, 59% reported verbal abuse in the workplace, and 32%

reported physical abuse (Buerhaus, DesRoches, Donelan, & Hess, 2009). These appalling

statistics are relevant for all Registered Nurses (RNs), regardless of their number of years in the

field. Unfortunately, the first year of nursing can prove even more challenging.

According to a study by McKenna, Smith, Poole, and Coverdale (2003), “the first year of

practice is an important confidence-building phase for nurses; however, this study indicates that

graduate nurses in their first year of practice are subjected to a variety of confidence-diminishing

behaviours” (p. 96). In order to diminish the prevalence of lateral violence toward newly

graduated RNs, the study emphasizes the importance of educating and training staff about

violence in the workplace. Prior to employment, however, the study stresses the importance of

implementing undergraduate education in order to enhance individual coping in relation to

adverse staff relationships (McKenna et al., 2003).

Evidence-based research shows that hostility in the acute care setting threatens patient

safety by negatively influencing nursing actions (Wilson & Phelps, 2013). It impairs judgment,

hinders the effectiveness of interventions, and alters behaviors. These hindrances can lead to

errors and sentinel events. One specific finding in the study noted that nurses who experience

hostility on the clock, are more likely to carry out an order they do not believe is in the best


interest of the patient. This is explicitly what Janet Jackson did (Wilson & Phelps, 2013). In

regards to the sentinel event at hand, two stressed nurses with a prior history of lateral violence

in an unstable environment, made a serious, but preventable mistake.

People

As defined earlier, the purpose of a root cause analysis is to find errors that contribute to

sentinel events within the system, without solely focusing on the individuals involved in order to

correct and prevent a future occurrence. After meticulous revision of the sentinel event and

completing the necessary interviews, one major contributing factor is the group of individuals

involved, both directly and indirectly.

Giselle, the primary nurse involved in the case, had a role in the occurrence of the

sentinel event by disregarding patient safety, evidenced by micromanagement and intimidation

toward Janet. After interviews were conducted on the unit, it was discovered that this negative

behavior dated back to Janet’s date of hire. In the past, this form of disruptive behavior has been

tolerated, excused, or seen as normal, but mounting evidence indicates it is a direct threat to the

safety of patients that results in medical errors, injuries, or death (Addison & Luparell, 2014).

Nurse Janet also contributed to the event occurrence, first by not reporting the bullying

earlier, and second by acting against her better nursing judgement. Nurse Janet, acting out of her

comfort level and knowingly against policy, removed the identification leg bands. Janet did not

conduct an assessment to see if circulation was affected by the bands, she merely wanted the

bullying to stop. Her nursing critical judgement was affected by the negative interaction with

Giselle, which caused her to perform under fear, stress, anxiety, and an evident loss of

concentration (Addison & Luparell 2014).


The secondary nurse also contributed to the sentinel event in two ways. First, she worked

against policy by witnessing the removal of the bands and retrieving new ones from the unit

clerk for Janet to place on the infants. Then, the secondary nurse chose to play a passive role by

not reporting the bullying of nurse Janet to avoid retaliation from Giselle.

The nurse managers and administrators also contributed to the sentinel event due to their

lack of awareness, and non-compliance of state law regarding nurse-to-patient ratio. State law for

licensed nurse-to-patient ratio states the minimum ratio in medical, surgical, and mixed units is

1:5 (Klutz, 2005). The morning the sentinel event took place, the nurses on the unit were

working on a 1:9 nurse-to-patient ratio. This is an unacceptable practice because growing

evidence has demonstrated an inverse relationship between the number of available registered

nurses to patients and hospital mortality (Kravits & Sauve, 2002).

Policy & Procedure

An internal investigation was performed and found that the nurse, with improper

implementation of the hospital’s policies and procedures, committed many errors. The following

errors contributed directly to the events surrounding the sentinel event. First, the nurse failed to

access the policy for clipping and replacing leg bands and performing proper identification of the

newborns. The nurse felt pressured to follow orders and did not critically evaluate the situation,

which caused her to fail to look into policy and procedure. Second, the nurse did not report the

harassment she was experiencing. A lack of training regarding the proper procedure for reporting

harassment played a large part in this.

A hospital cannot function properly without good policies and procedures in place

(Randolph, 2006). Furthermore, Rao claims managers cannot function adequately without

policies and procedure (n.d.). Without set policies and procedures, managers would not have a


framework for proper care and decision making. In order for policies and procedures to be

effective, they must be clear and easy to understand. However, if a hospital fails to teach and re-

educate new nurses on policies and procedures, the nurse may have a brief lapse of judgment in a

critical situation, which is precisely what occurred in Janet’s situation.

Equipment & Technology

In the case of Mason Michael, technology and equipment largely contributed to the

sentinel event. The new nurse did not use a scanner to verify the identification of the newborns

prior to exchanging their new and old bracelets. Incorrect patient identification has been shown

to lead to adverse patient outcomes (Kalisch & Xie, 2014). The nurse should have inquired about

the use of a scanner for patient identification. The bracelets could have also been misprinted

without the new nurse’s knowledge because she was not the nurse who retrieved them from the

ward clerk. Pediatric band misidentification can be prevented when staff communicate

effectively and utilize the interventions outlined in their hospital’s policy and procedure manual

(Phillips, Saysana, Worley, & Hain, 2012). The secondary nurse did not communicate properly

with Janet Jackson when she was handing over the legbands. Although she was trying to help the

nurse, her actions increased the likelihood that the sentinel event would occur. There should be

other policies implemented to improve patient identification. According to Gray, Suresh,

Ursprung, Edwards, Nickerson, Shiono, Pisek, Goldmann & Horbar (2006), patients are at risk

for misidentification due to the similarity of standard patient identifiers. By thoroughly

following the proper steps in patient identification, a sentinel event could have been prevented.

Management

One of the main causes of the two babies being switched at birth was the conflict between

the nurses, Janet and Giselle. Their managers did not intervene and correct the lateral violence


early enough, which may have prevented the sentinel event entirely. Nurse leaders must enforce

the hospital’s norms, provide support to their nurses, and be role models; all of which can help

curb disruptive behaviors (Yragui, Silverstein, & Johnson, 2013). Yragui et al. (2013) also state

that strong support from management leads to better employee behavior and “higher quality of

patient care.” The lack of proper management and support for employees, directly contributed to

the sentinel event.

Communication

Good communication is a key factor in working amongst others effectively, both on a

one-to-one basis and in a group setting (Groves, 2014). Good communication involves not only

words, but also non-verbal communication and most importantly, being a good listener.

Furthermore, good communication is necessary due to its direct affect on colleagues, working

environment, quality of care, patient response and outcome (Groves, 2014).

Recently, there has been a great focus of attention on improving communication that

leads to safe patient outcomes. For example, communication is among the seven National Patient

Safety Goals provided by the Joint Commission (Puppe & Neal, 2014). In addition,

communication is a central component in the Institute of Medicine’s campaign to promote a

“culture of safety” by incorporating safety competencies, collaboration, and teamwork (Puppe &

Neal, 2014). After the review, it was discovered that a notable lack of teamwork and

collaboration occurred on the unit the morning of the sentinel event. This produced multiple gaps

in the safety competencies, thereby leading to the switching of the newborns. Later in the

investigation, it was also discovered the hospital had stopped requiring attendance to

communication skills training classes, two years prior. Optional attendance led to significantly


less involvement by the employees. The ineffective communication used by Giselle could have

been averted if attending the communication classes was enforced.

The healthcare environment leaves no room for negative or ineffective communication.

Results provided from root cause analyses of sentinel events, performed by the Joint

Commission, found 70% of events were traceable to a dysfunction in communication among

health care providers (Rosentein, 2011).

Change Driven Action Plan

The Joint Commission recommends that when sentinel events occur, a “thorough and

credible root cause analysis and action plan” should be completed (Ewen & Bucher, 2013). Once

the root cause of the sentinel event is determined, the team reviewing the event will determine

strategies and put together an action plan to try and reduce the event from happening again.

According to Ewen and Bucher (2013), it is important to focus the strategies of the action plan

on issues related to the systems and process, rather than issues of individual performance or

behavior. This approach is more likely to reduce the chance of recurrence of the sentinel event.

Action plans should include definitive acts that are easy to understand, and are directly related to

a specific root cause. Lastly, Ewen and Bucher (2013) state a system should be put into place to

measure the effectiveness of individual actions defined in the plan.

Targeted Change

The targeted change is to reduce the incidence of sentinel events by decreasing disruptive

behaviors among nurses. Disruptive behaviors are any behaviors that are disrespectful to other

people, or any interaction at the interpersonal level that interferes with safe patient care

(“Disruptive and Unprofessional Behavior,” 2014). Disruptive behaviors prevent cohesive

teamwork in the hospital, which undermines the potential of developing a safe work environment


where quality patient care can be delivered. This was evidenced by the incivility between Janet

and Giselle, which resulted in the two babies being switched shortly after birth. The targeted

change will include a confidential system to report disruptive behavior, training that promotes

teamwork and communication, implementation of a zero-tolerance policy, and disciplinary

action for those who continue to engage in behaviors that are not safe (“Disruptive and

Unprofessional Behavior,” 2014).

Stakeholders and Roles

Stakeholders are “persons or groups that have a vested interest in a clinical decision and

the evidence that supports that decision” (Agency for Healthcare Research and Quality, 2014).

The seven different groups of stakeholders in healthcare are the consumers, clinicians, health

care institutions, purchasers and payers, health care industry, policymakers, and researchers. The

consumers include patients, caregivers, and patient advocacy organizations. The consumers are

the ones who directly experience the situation and suffer negative outcomes when disruptive

behaviors lead to sentinel events. This would also prevent consumers from seeking the services

of a hospital, known to be an unsafe environment. The second group includes clinicians and their

professional associations. Clinicians are ultimately the ones who make the medical decision, and

their decision may be hindered when there is a breakdown of effective teamwork and

communication. The third group is the health care institution, which includes hospitals and

medical clinics. Individual institutions are responsible for investigating sentinel events,

monitoring changes, and enforcing plans such as zero-tolerance policies. Purchasers and payers,

comprised of employers and insurers, make up the fourth group of stakeholders. A high

incidence of sentinel events may cause hospitals to lose certain purchasers and payers. The fifth

group, the healthcare industry, is affected by slowing the development of new treatments and


devices. Hospitals may have less funding when sentinel events occur, which leads to fewer

purchases from the healthcare industry as a whole. Policymakers at the federal, state, and local

levels are the sixth group. According to the Agency for Healthcare Research and Quality,

“policymakers at all levels want to make health care decisions based on the best available

evidence about what works well and what does not” (2014). It has been shown that a root cause

analysis and action plan is effective in dealing with disruptive behaviors in the workplace. The

seventh, and final, group of stakeholders are the researchers and research institutions. They are

responsible for obtaining evidence from various sources related to sentinel events, and analyzing

the effectiveness of changes made in response to those events (Agency for Healthcare Research

and Quality, 2014).

Target Population

The target population for the change in action plan includes all staff involved in patient

care. Physicians, nurses, managers, and non-licensed personnel need to be able to work together

effectively in order to provide safe patient care. A zero-tolerance policy, accompanied by

disciplinary action, is important to combat disruptive behavior, and no staff member is exempt

from this policy (Longo, 2010). The staff involved in patient care should also go through a

mandatory cognitive rehearsal and communication training. Studies have shown this kind of

training to be effective in reducing bullying and lateral violence among nurses, which can

prevent the occurrence of a sentinel event (Longo, 2010).

Plan for Change Using Kotter’s Eight Steps to Transforming Your Organization

Establishing a Sense of Urgency

The first step in Kotter’s change theory is the act of establishing a greater sense of

urgency (Kotter, 1995). Kotter (1995) claims that “without motivation, people won’t help and the


effort goes nowhere” (p. 60). In order to establish the importance of the situation at hand,

employees must recognize that a significant amount of effort is being made to facilitate a change.

A recent review of Kotter’s model for change, discloses a situation in which the CEO of a

company

travels to various corporate locations in order to discuss the need for change. This type of

oral persuasive communication not only allows the message itself to be communicated,

but also, the importance of the issues to be symbolically magnified by the fact that time,

effort, and resources are utilized to communicate the changes directly. (Appelbaum,

Habashy, Malo, & Shafiq, 2012, p. 767).

In order to instill a similar sense of urgency among hospital staff, nurse managers and

hospital administrators will take an aggressive approach by holding group meetings and

organizing randomized informational breakout sessions. These gatherings will aid in the

initiative by “showing the attractiveness of the change, confronting employees with clear

expectations, showing that it can be done and creating a positive attitude to the change”

(Appelbaum et al., 2012, p. 767). Applebaum et al., (2012) agree that accomplishing Step 1 is

still as beneficial in 2011 as it was in 1996. The ultimate goal is for staff to understand that

change is necessary, and the management team will not stop until a constructive adjustment has

been made (Appelbaum et al., 2012).

Forming a Powerful Guiding Coalition

Kotter’s (1995) second step for change involves the formation of a powerful guiding

coalition. The tactic of involving only the anticipated administration team is weak and

predictable; however, encompassing nursing staff and outside parties into the initiative leaves a

more substantial impression. Kotter (1995) claims “in successful transformations, the chairman


or president or division general manager, plus another 5 or 15 or 50 people, come together and

develop a shared commitment to excellent performance through renewal” (p. 62). Regardless of

the management’s capabilities or dedication to the initiative, groups without strong leadership

fail to gain the power necessary for change (Kotter, 1995).

In order to accomplish Kotter’s second step, hospital management must convince a

minimum number of employees, dependent upon the size of the establishment, that the plan for

change is productive and imperative for the well being of individual employees, patient

outcomes, and the hospital as a whole. Applebaum et al., (2012) point out that a strong guiding

coalition includes the support of employees with position power, expertise, credibility, and

leadership. Each of these key elements provides different benefits, enabling the coalition to drive

forth with power, intelligence, and respect. Similar to step one, this phase will be achieved by

spreading the word through group meetings and shift breakout sessions. Specific key players will

be sought out to join the coalition, in hopes of strengthening the initiative.

Creating a Vision

The third step in Kotter’s (1995) model for change is the act of creating a vision.

According to Kotter (1995), every successful transformation previously witnessed has enveloped

a “picture of the future that is relatively easy to communicate and appeals to customers,

stockholders, and employees” (p. 63). Creating a clear picture of the future helps clarify the

organization’s direction (Kotter, 1995). In their personal experiences with change initiatives,

Washington and Hacker (2005) claim that those “who understood the change were more likely to

be excited about the change, were less likely to think the change would fail, and were less likely

to wish that the change had never occurred” (p. 408). Unfortunately, the task of creating a clear

vision is not achieved overnight. The coalition typically works at clarifying the vision for several


months, and eventually a strategy is developed to achieve the vision (Kotter, 1995). In the event

that step 3 is evaded, “a transformation effort can easily dissolve into a list of confusing and

incompatible projects that can take the organization in the wrong direction or nowhere at all”

(Kotter, 1995, p. 63).

In order to implement this step, the newly formed guiding coalition must collaborate and

agree on the vision. This will be achieved through a series of meetings over a several month

period, or until the vision has been established. Kotter (1995) shares a “useful rule of thumb: if

you can’t communicate the vision to someone in five minutes or less and get a reaction that

signifies both understanding and interest, you are not yet done with this phase of the

transformation process” (p. 63). That being said, the guiding coalition must spend the necessary

time to ensure the vision is clear and comprehendible to others (Kotter, 1995).

Communicating the Vision

The fourth step in Kotter’s (1995) model for change is the act of communicating the

vision. After several months of developing the perfect vision, many companies make the mistake

of utilizing only a single outlet for communication, such as mass email or management speeches

(Kotter, 1995). A more effective alternative is to utilize every method of communication. The

guiding coalition is responsible for turning

boring and unread company newsletters into lively articles about the vision. They take

ritualistic and tedious quarterly management meetings and turn them into exciting

discussions of the transformation. They throw out much of the company’s generic

management education and replace it with courses that focus on business problems and

the new vision. (Kotter, 1995, p. 64).


A study, conducted by Frahm and Brown (2007), reported that opening up channels for

communication allowed employees to be trusting and open with their opinions on the initiative.

Whereas, employees who were not well informed on the initiative for change felt frustrated

(Frahm and Brown, 2007).

In order to implement Kotter’s (1995) fourth step, the guiding coalition must initiate mass

communication of their efforts, utilizing all channels of communication. It is important to note,

however, “communication comes in both words and deeds, and the latter are often the most

powerful form. Nothing undermines change more than behavior by important individuals that is

inconsistent with their words” (Kotter, 1995, p. 64). Therefore, it is important for the leaders of

the coalition to act on the words of their initiative for change, while delivering the vision.

Enable Action by Removing Barriers

In Kotter’s (1995) change theory, the fifth step is to enable action by removing any

barriers. This step allows for change to move forward without any obstacles. Any obstacle that

may hinder reaching the goal should be removed. Kotter (1995) states that there are usually four

types of barriers that prevent people from changing within their organization, and they include

formal structures already established to make it difficult to change, immediate supervisors or

bosses that do not want to implement the new change, staff or technical systems that make it

challenging to change, and the lack of specific skills that hinders the change (Kotter, 1995).

Recognizing these barriers will help to address the issue and make the necessary

change. In the story of switching the babies at birth, these barriers can be identified in helping

create the change that will occur smoother, with fewer obstacles to overcome. During staff

meetings and breakout sessions, attention will be directed toward identifying specific barriers

that cause hindrance to change.


Generate Short Term Wins

Kotter’s (1995) sixth step in the change model is generating short-term wins. In this step,

short-term wins are generated to build and gain momentum. By building and gaining momentum,

it allows the change to continue moving forward and it keeps the individuals involved to

continue to work hard and stay committed to the change. As with most short-term goals, it is

important to identify the common themes. They include having goals that are measureable,

visible, timely, relevant to stakeholders, and relevant to the situation (Kotter, 1995).

In order to implement this change, staff will need to generate some short-term goals. As

in the case of switching the babies at birth, a short-term goal could be ensuring that two nurses

verify the correct legband is placed on the correct baby as soon as delivery is complete. This goal

can be set to a timeframe of one month and then reevaluated for its success. The goal is relevant

in preventing the babies from getting switched at birth.

Sustain Acceleration

The change model requires sustained acceleration of the goal. This is Kotter’s (1995)

seventh step in his model of change. In this step, change is evolving and the goal is to maintain

the change in the direction desired. According to Kotter (1995), this is when changes that are

successful will see more projects added, additional staffing is brought on to support and help

with the change, staff is empowered at all levels, there is a reduction in interdependencies, effort

from team members is high to keep the sense of urgency, and there is a constant reminder that

the change implemented is working. Kotter (1995) also mentions that it is important to continue

to remove or minimize the barriers that were noted earlier in the change model. This is to help

sustain the momentum and not have any deviation of the planned change.


This step is important in the model of change because this is when goals are being

realized and the change is starting to work. With proof that the change is working, more staff

will usually get on board and support the initiative. This helps advance the change process and

allows it to be a success.

Institute Change

The final step in Kotter’s (1995) change model is instituting the change. Once the

initiative has gone through the other seven steps, it is now time for implementation. Kotter

(1995) mentions that it is important to recognize the new direction is superior to its predecessor,

and the change was implemented for the correct reasons. At this stage, it is also important to

reinforce the new changes by offering incentives or rewards, such as raises and potlucks, in order

to perpetuate continuous agreement that the new direction is the desired path. Monthly audits, by

a team of nurses and nurse managers, will determine the compliance of the employees. These

audits will reevaluate the change process and whether it is moving in the desired direction or not.

The compliance audits will help in sustaining the momentum of the plan and to ensuring the

change is instituted.

After discovering blood incompatibility with his parents during a school science project,

Mason Michael came to the realization that he was involved in a major sentinel event at St.

Petersburg Medical Center in Merced, California. Consequently, The Joint Commission and St.

Petersburg Medical Center completed a root cause analysis of the sentinel event. Research shows

that lateral violence contributes to sentinel events in healthcare settings. For this reason,

proposed action plans for change are implemented to prevent reoccurrence of these sentinel

events. Through the application of Kotter’s (1995) model for change, issues will be addressed


and attitudes will be altered for enhanced policy adherence, collaboration, and improved patient

safety outcomes.


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