Catch of the month!

Sep 13, 2018 | News

This month's "Good Catch" Award goes to Elizabeth on 3BC at Mount Saint Joseph Hospital.

Way to go, Elizabeth!!

Good catch: Upon reviewing the Medication Administration Record for one of the patients she was providing care to, Elizabeth noted new medications that, if administered, could have the potential to cause severe harm based on the patient’s current medical diagnosis. Elizabeth questioned the orders with the Most Responsible Physician (MRP), and both determined that the  new medications were prescribed to the wrong patient. 

The ability for Elizabeth to feel safe and question medication orders exemplifies how working in a psychologically safe environment enhances patient safety!

Near misses are opportunities to prevent harm to patients in the future.

A near miss in medicine is an event that might have resulted in harm but the problem did not reach the patient because of timely intervention by healthcare providers or by good fortune. Near misses may also be referred to as "close calls" or "good catches." In a culture of safety, near misses are "free lessons." Near misses may occur many times before an actual harmful incident. Further, many avoidable deaths have a history of related near misses preceding them.

Providence Health Care view near misses as learning and improvement opportunities by asking, "How will the next patient be put at risk or harmed?” PHC values and acknowledges input from those who care for patients, and make appropriate improvements.

Why are near misses important?

They represent "error prone situations" and "error traps" waiting to catch other patients and providers. There is less anxiety about blame because no one has been harmed.

Why should near misses be reported?

Reporting near misses helps to:

  • Reduce risks for all patients by not waiting for harm to occur
  • Trigger improvements in weak spots in the processes of care
  • Alert other providers to possible vulnerabilities and gaps in training
  • Contribute to planning, recovery testing, and harm mitigation strategies following  events that do result in harm

Be sure to stay tuned to this space for next month's Good Catch award recipeint!

PDF icon good-catch_sept2018_poster.pdf
Quality & Safety

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