Transcript Title Page of Presentation - Center for Patient Safety

The “Good Catch” Program
Vereline Johnson, MSN, RN
Patient Safety Officer
Amy Cutler, PhD, RNC, NNP, PNP
4/3/2016
Background
• Developed by Dr. Robert Massey, Director of
Clinical Nursing and The University of Texas
M. D. Anderson Cancer Center in 2005.
• Since 2005, M. D. Anderson has received
over 82,000 reports of events before they
could reach the patient.
• The program is becoming a national model
for development of similar systems.
2 4/3/2016
Purpose
• Encourage staff to report potential patient
safety errors, commonly referred to as “near
misses” or “close calls,” that they identify and
correct them as part of their daily practice.
• Reporting such instances allows for analysis
of systems and factors that may contribute to
errors.
3 4/3/2016
Overall Goal
• To change the culture of error reporting by
shifting the emphasis from the negative
implication of a “near miss” or “close call” to
focus positively on employees’ actions to
identify and prevent potential errors with
medications, equipment, and patient care.
4 4/3/2016
NICU Good Catch Program
5 4/3/2016
Discovering the Challenge
• Some shocking numbers
• Pediatric patients experience 3 times more
potentially harmful errors than the general adult
population.
• 1.9% infants experienced serious harm, causing
life threatening or significant damage from errors
(VON)
• Medication errors account for more than 18%
• Neonates rank among the highest at risk groups
for healthcare associated infection
6 4/3/2016
Discovering the Challenge
• Estimated that nurses only report 5% of
significant errors:
• Fear
• Disagreement over if an error really occurred
• Administrative response
• Reports too time consuming
7 4/3/2016
NICU Good Catches - 90
• Medication Order Error (9)
• Medication Dispensing Error
(23)
• Missed/Failed Treatment (9)
• Transcription & Communication
Error (17)
• Procedure Issues (8)
• Infection Control (1)
• Equipment/Devices (11)
• Fall Prevention (1)
• Other (11)
8 4/3/2016
Achieving Change
• Good Catch now administrated by staff
• Good Catches moving beyond the obvious to those that
require some thought
• Everything nurtured, will grow.
Accept the Challenge
• We have accepted the
challenge…will You?
10 4/3/2016
Process for Reporting a Good Catch
1. Recognize/discover a potential patient safety
problem and take corrective action.
2. Complete the “Good Catch Award
Submission Form.”
3. Send or fax the completed form to the
Performance Improvement Department.
11 4/3/2016
Good Catch Rewards
• Good Catch Award Certificate.
• Coupon redeemable for a drink or ice cream
treat in the Tuscan Sun restaurant.
• Consideration for the Good Catch of the
Quarter Recognition.
• Personal satisfaction for contributing to
improved patient safety.
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Certificate
13 4/3/2016
Coupon
14 4/3/2016
Examples of a Good Catch
• Discovering an expired medication prior to
administration.
• Preventing a patient fall.
• Recognizing the label on an IV infusion does
not match the pre-printed information on the
bag.
• Discovering a sterile dressing package is
torn/compromised.
15 4/3/2016
Summary
• “We’re trying to create a fair and supportive
culture in which nursing staff feel empowered
to identify opportunities to improve patient
safety and eliminate any fear of reporting.”
Barbara Summers, Ph.D., Vice President and Chief Nursing Officer,
The University of Texas M. D. Anderson Cancer Center .
16 4/3/2016