We had a near miss today. Near misses have been on my mind a lot lately…both professionally with the work we do to improve patient safety, and at home. We talk about near misses and adverse events during morbidity and mortality rounds (M&M rounds) at work…and I thought, I’d really like a parenting M&M round. I mean, I really really really want to keep my children safe, as I’m sure all parents do. Let’s face it, reading position statements and news articles and baby and toddler books is a pretty dry, non-personal way to learn about keeping our kids happy and safe, am I right? Maybe it would be better to make it more personal. Maybe there is a lot of wisdom out there within my fellow parents…maybe if we share our lessons less of us will have to find out the hard way.
M&M rounds in the hospital are anonymous. When we discuss a case we de-identify it so that the providers and nameless and faceless. Why? Because there but by the grace of god go I. Any one of us can have a case brought to rounds and most of us will at one time or another. We all make mistakes. Anonymity is thought to decrease blaming, shaming and all those negative unproductive things.
So please, if you have something to share, protect your identity.
M&M rounds occur in a climate of “psychological safety.” We do not blame, we do not belittle, we do not make nasty comments or call names.
The purpose of M&M rounds are to work as a group to find solutions. Solutions are best when they do not rely on individuals working harder or better. We want to identify system changes, routines, standard ways of doing things that will make near misses and adverse events (harms) less common.
So here is the case. We (and I’m saying we because my family and I are de-identified through my internet alias) have a baby gate at the top of our staircase. It is a pressure gate because the railing is metal and we couldn’t figure out how to use a fixed hardware gate. This morning my son was rattling the gate when it opened and he swung, holding onto it, out over the stairs and into space. I was right behind him and managed to grab him and pull him to safety. He was upset and scared…but not as much as I was.
The only reason that this was a near miss instead of a trip to the emergency department was that I was lucky enough to be RIGHT THERE when it happened. And I guess also that my son was strong enough to hold on during the swing.
Possible corrective actions (one or more may be appropriate…we like multilevel solutions):
Change out the gate from a pressure gate to a fixed hardware gate. Perhaps there is way to use a gate that would attach to the railing. Does anyone know of such a modification or system? The problem with pressure gates is that as the pressure loosens over time as the gate is opened and shut (and rattled by a toddler). When the gates are loose, the catch isn’t very robust and the gate will open with pressure without having to press the buttons while simultaneously lifting the handle.
Modify the gate so that it only opens in one direction – i.e. will swing into the hallway at the top of the stairs but NOT out over the stairs. Has anyone done this or thought about how it could be done?
Periodically tighten the gate. Here’s the thing, I know that pressure gates loosen. I’ve periodically tightened our gates. I had been thinking that I should tighten the gate at the top of the stairs for a while..the “click” when shutting it had started to sound “mushy” rather than “crisp.” But I didn’t bother to do it. I’m thinking of adding gate tightening to a repeating periodic event…like say, we do it every time we put the monthly flea medicine on the dog or we do it on garbage day. I think that making it a set activity, and maybe even putting it on the calendar, will help me actually get around to it.
Teach my son NOT to rattle gates. I’ve been well…maybe lazy about this? He likes to climb iron fences and rattle fences and gates…and I let him. I supervise/ spot the climbing but that isn’t teaching him much…and baby gates look just like garden gates.
Continue close supervision around the baby gate. I don’t like this solution because it relies on individuals working “harder” and lets face it, there are going to be gaps in supervision now and again. You can’t helicopter your kids all the time. But as a solution that fits in with some or all of the above, sure. Right now, hubs and I are VERY cognizant of the danger lurking at the top of the stairs…but some time will go by and our vigilance will drop. So we need a better solution. Plus we’ve also had some problems with leaving the baby gate open…i.e. forgetting to close it. So how vigilant are we really?
Get rid of the baby gate. I’m not sure about this but I have noticed that those times that we have left the baby gate open, our son has not exactly launched himself down the stairs. He can walk down stairs, but will only do so if he can hold onto a railing or our hands and he waits at the top of the stairs for us to help him. Because the railing on our stairs is a glass panel within a metal frame, he doesn’t have anything to hold onto if we aren’t there. If there are only three or four stairs (like our front stairs) if he waits too long he will turn around and climb down backwards but he hasn’t tried that with the main staircase yet. So right now, it might actually be safer to get rid of the gate. For now. At some point he will try to walk down the stairs on his own so the success of this plan would rely on us noticing when he is about to try that and putting the gate back up or waiting for him to try it and stopping him and getting the gate back up before he hurts himself.
What sort of near misses or problems have you had with baby gates? What corrective actions did you take?