Lessons Learned

Although the drills and exercises are critical to identifying ways to improve our response to these types of incident, they sometimes do not fully prepare you for real emergencies. Key lessons learned were:

  • Training, Training, Training — This needs to be done for all team members and continuously tested to ensure everyone is fully trained on how to perform procedures that may occur infrequently.
  • Simplified Processes — The operator’s software system is very powerful, but we had created some complicated processes that made it more difficult to quickly send out urgent “All Page” messages.
  • Clear Communication for Notifications — During major incidents such as this, misinformation can easily be communicated to the operators. It’s important they have one key contact to provide all instructions on what is needed from them. The confusion over the “Code Silver” being cleared early was due to security not being aware of what notifications the operators were being instructed to send.
  • Additional Staffing — With the lead operator out sick, the remaining operators did not feel empowered to reach out for additional help. The call center team needed procedures on how to escalate quickly when major incidents such as this occur.
  • Ongoing Communication During Events — The hospital operators received huge volumes of calls from people wanting information. They had to continuously inform family members and the media that they did not have any information. This caused stress for the operators and frustration for the callers.
  • Mass Communication System — With changes in personal technology, many team members and physicians have moved away from pagers and use their personal devices for receiving messages. Key personnel did not receive messages about the event until they awoke on Sunday and checked their email or heard it from the news outlets. A system that allows critical audible alerts to personal devices is essential.