Catch of the month!

Jan 4, 2019 | News

Congratulations to our “Good Catch” Award winner, Lindsay from St. Paul's CICU!

(l to r) Lindsay (seated) and her fellow CICU staff members, celebrating her “Good Catch.”

Good Catch

While completing the “7 rights” of medication administration, Lindsay noted the wrong medication, thiamine, within a patients’ medication strip (it had not been ordered nor was it on the MAR). The right medication, Aspirin, as per the MAR order, was missing.

What Was Learned

A practice standard for all nurses is adhering to the “7 rights” that support safe medication administration. Even in a tech-savvy environment, medication errors can happen because people are part of the process. This is a great lesson to showcase that we are fallible and the fundamentals of checking holds value for safer patient care.

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_dec_2018_poster.pdf
Quality & Safety

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