Catch of the month!
Submitted by Sarah Carriere, leader, Patient Safety
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!
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- Lights, camera, celebrate! PHC Long Service Awards starring our 2017 recipients
- 'The love of my life was sacrificing a piece of himself to help me get better'
- 'The staff continue to exceed expectations,' says son, of mother’s care at Mount Saint Joseph Hospital
- St. Paul's Gift Shop takes steps to curb rampant shoplifting
- 6 tips to create a safe workplace and reduce theft
- Online paycheques coming soon for PHC staff
- Dr. Krahn and team receive $772,650 CIHR project grant
- The Doctors Are In podcast: Getting ready for go-live
- On January 31, let's talk about mental health
- Physiotherapy 101: Top tips to stay healthy on the slopes this winter
- Buy your tickets for Scotiabank Feast of Fortune!
- Take part in PEDAW 2018!
- Time to test your brain - Ethics Case of the Month is here!
- Dear EFAP: My new man needs a makeover!
- New standards outline payment amounts to use when engaging people with substance use experience
- Data Privacy Day 2018: Are you using your mobile devices safely?
- Psychology month public lectures announced
- Writing winning (hopefully!) award applications
- Register now for the Geriatric Services Conference and be entered to win a tablet
- St. Paul's Hospital needs magazine donations
- SPH February vendors announced
- Have a Buddha-full weekend!