Catch of the month!

Jan 25, 2018 | News

Congratulations to Nick and Cheryl, our "Good Catch!" winners for January 2018!

Good catch: When Nick went to review the medication profiles for two patients newly admitted to the 7th floor, he found that the Medication Reconciliation (Med Rec) process was not used, in addition to many medications having not been ordered, or the wrong medications were ordered.

What changes were made? Once Cheryl was notified of the situation and the PSLS, within that week she was able to gather a multidisciplinary group to develop a new admission process for chronic pain patients admitted to Medicine in order to streamline the process and prevent a similar event from happening again.

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_jan2018_nick-cheryl_poster.pdf
Quality & Safety

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