Catch of the month!

Aug 30, 2018 | News

Congratulations to Emily, our "Good Catch!" winner for August 2018!

Good catch: Upon reviewing the Medication Administration Record with another colleague in order to double check a medication, Emily, LPN, 4E MSJ, noted that the description of administering naloxone was different to how it was usually prescribed, i.e., it was prescribed to be given for prevention and interpreted as a regular order, as opposed to administration for an overdose.

The ability for Emily to feel safe and question something that felt amiss exemplifies how working in a psychologically safe environment enhances patient safety!

Emily (centre in pink scrub pants) with some of her colleagues.

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 health care 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 for next month's Good Catch award recipeint!

PDF icon good-catch-emily-august2018.pdf
Quality & Safety

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