Any time you can catch a mistake before it happens, there’s reason to celebrate. That’s especially true in a hospital, where even little mistakes can have serious consequences.
A “Good Catch” program was implemented at the Health Center’s John Dempsey Hospital early last year to encourage employees to watch for potential mistakes and to celebrate intervention.
“Our goal is to intervene before something happens, and then follow up by reviewing the processes in place to see if we can prevent similar ‘near misses’ in the future,” says Rhea Sanford, co-director, with Dr. James Menzoian, of the Collaborative Center for Clinical Care Improvement.
The Good Catch program is one part of a broad initiative designed to improve safety in the Health Center and make John Dempsey Hospital the safest in the state.
“One of my favorite good catches was made by an employee in the facilities management department who was on a ladder in a patient’s room changing a light bulb,” says Sanford.
“He happened to notice that tubing to a patient’s oxygen supply was being pulled while the patient was being moved, and pointed it out before anything happened. It’s not enough for only patient care providers to be concerned about safety; the responsibility for a safe hospital spreads out to all employees.”
Every two months, the hospital’s Patient Safety Committee reviews the Good Catch nominations, which may be submitted by anyone in the Health Center.
A certificate and a Good Catch pin goes to each winner.
“Our staff has embraced the Good Catch program in a way that has been fun and has really caught on,” says Sanford.
Adds Menzoian: “It’s about celebrating a culture of safety for all our patients.”
| Susan Richmond, an employee at the Health Center, was recognized for a “good catch,” in a program designed to improve safety at the hospital.
|Photo by Susan Garthwait
Good Catch awards have been made to employees for checking for correct wristbands on all patients, reviewing proper orders for doses of cardiac medications, checking for outdated medications on hospital carts, verifying the transcription of medication orders, reviewing medication packaging to avoid confusion, and identifying all patients by their full names and medical record numbers or birth dates.
“We want to encourage employees to report problems without their worrying about being blamed for them,” says Sanford.
“Ever since 1999, when the national Institute of Medicine released its report showing that medical mistakes are common and often potentially life-threatening, there has been a growing awareness in the health care community that mistakes are not always a result of carelessness or individual experience. Instead, they are often related to breakdowns in the system of care. So we are looking at processes and systems. We’re establishing checklists and read-back procedures. We’re getting away from handwritten orders. We’re improving training and focusing more on safety.”
The Collaborative Center for Clinical Improvement has involved staff throughout the Health Center in separate safety committees, each with its own targeted area and leader, to improve patient safety and quality of care in areas including infection control, pain assessment, patient falls, medication safety, organizational culture, and performance improvement measures.
Says Sanford, “Our Good Catch program is one part of our overall emphasis on safety and quality care.”