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Eve Tang, a nurse at Toronto General Hospital, couldn't figure out how she had slipped on a dry floor while walking into a patient's room.
Fortunately, she caught herself on a nearby chair and was able to avoid any serious injury.
After getting back on her feet she took a closer look at the floor – the spot she slipped on was like a sheet of ice compared to everywhere else.
Mopping the area didn't eliminate the slippery patch, so Eve reported the incident immediately. She and the unit manager, Marleine Elkhouri, went and took a closer look.
"Marleine realized it was baby powder on the floor," says Eve. "Even when we knew what it was we had trouble getting rid of it. We put it on the safety huddle board and it was raised the next morning at huddle."
The powder, applied during morning care to make patients feel more comfortable, can also make floors incredibly slippery – in fact professional dancers often apply it as a remedy for sticky floors.
It also poses a risk to patients with respiratory sensitivities. Many other areas at UHN have already banned it and going forward it will no longer be stocked anywhere at UHN.
"I'm just glad it was me, instead of the patient I was going to mobilize. She was an older lady and very fragile," says Eve. "It could have been a lot worse."
And what does Eve think of the unit's response to the incident?
"Since we started the safety huddles a couple of months ago issues are getting resolved and changes are happening quickly," says Eve. "It makes our job as nurses easier and we are able to work more safely and efficiently."