Fail Often To Succeed Sooner: Adventures in Innovation


Christi Dining Zuber, RN, MHA; Victor Alterescu, RN, MBA, MPH; Marilyn P Chow, RN

Fall 2005 - Volume 9 Number 4

https://doi.org/10.7812/TPP/05-098

A new mom lies in bed in the Postpartum unit as a Kaiser Permanente (KP) Certified Nursing Assistant (CNA) wheels in a TV/video cart so mom can watch an educational video about circumcision before her baby's procedure. Just when the CNA plugs in the video, another staff member enters to complete the baby's hearing screening. The CNA abruptly turns off the video and wheels the cart out of the room. The screener asks, "Has your baby been fed in the past hour? We want him restful and quiet for the hearing screen." "No," the mother replies, "I didn't know that you were coming." "I'm sorry," the screener says, "that means I can't perform the test now. I'll have to come back." She then leaves the room. The new mom missed the educational video and the baby missed his hearing screening; two clinicians wasted their time; and care and teaching for both mother and baby were delayed. Both caregivers will have to return unsure if the situation will repeat itself.

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