Tuesday, September 13, 2011

Good catches are catching on

For every adverse event that is reported in a hospital, there are likely 100 or maybe 1000 near misses that often go unreported.  Those close calls contain a wealth of information regarding systemic problems within a hospital.  Some hospitals have expanded their computerized reporting system to catch these problems.  For example, Children's Hospital in Denver did this.  After an electronic, web-based, secure, anonymous reporting system for anesthesiologists was put in place, a total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period a year previous.  "This . . . provided data to target and drive quality and process improvement."

Johns Hopkins uses another approach, a Good Catch Award. As noted in this paper presented to the Maryland Patient Safety Center last year:

The Good Catch Award creates positive incentives for providers and staff to report patient safety events. At the institutional level, the Good Catch Award encourages individuals to identify and report adverse events, near-misses, or other medical errors. The program rewards individuals who contribute and has been received positively by many providers and staff. The pilot phase of this program focused on identifying defects in the perioperative environment and devising a partial solution. The current phase of the Good Catch Award program shifts its focus to sustainability and strategies to maintain the implemented systems changes that resulted from the 13 Good Catch Awards given in the past two and a half years. This includes an educational component for providers, one of the original steps in the Good Catch Award process, to ensure better dissemination of information and implementation of systems improvements throughout the ACCM department. The program is ongoing in its effort to identify defects, formulate solutions, and recognize those who actively work to create a safer environment.

Here's a summary chart of the results:

This kind of program also exists at the University of Connecticut Health Center.  As noted:

John Dempsey Hospital's goal is to change any negative perceptions healthcare providers and others may have about reporting errors. Staff is encouraged to report near misses. It helps to identify areas where patients’ quality of care and safety might be improved. Reporting a near miss is considered a “good catch” and comes with rewards:

  • Good Catch award certificate.
  • Good Catch lapel pin.
  • Special recognition within the Health Center community.
  • A copy of the award certificate in Human Resources personnel file.
  • Sincere thanks for dedication to patient safety and personal satisfaction.
  • Reviews of all good catches to determine if additional safety measures should be implemented.
At our hospital, we had a Caller-Outer of the Month Award, similar in concept.  Instead of honoring someone who had solved a problem, our Board decided they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems. 

These are all variations on the theme. All approaches lead to much good and are worth a look to be considered for emulation elsewhere.


Peter said...

From Facebook:

The space for improvements is as wide open as your willingness to see. Can't believe this hadn't need standard practice for decades.

Anonymous said...

As a CRNA I would have to ask who did the reporting on the Anesthesiologist?

Many times to non anesthesia personnel something may look wrong but it really is not.

If the reports were by anesthesia providers it would need investigation.

Paul Levy said...

Wow, you are showing a bit of defensiveness! You need to get past that and think about this in a no-blame kind of way.

The idea is to receive reports from anyone who sees something they think is awry. Of course, you would want to evaluate each one.

Dianne said...

I believe that even the average provider makes safety "catches" every day. In my institution the only "catches" that are recognized by admin are the ones that practitioners tend to blow their own horn about. The overall sense is that those who have to make their "catch" public have a need to live in the limelight. These types of programs, although they look good to administrative types, almost discourage others since they feel their value is unrecognized and therefore unappreciated. It is everyone's duty, and it should be the expectation, that ALL providers make safety catches, every day. A reward system also tends to weight one catch as more valuable than others. They are ALL valuable.

The better way to capture data is to make it anonymous, as you mention in your post about the Children's Hospital. This is very similar to the NTSB ASRS program, which allows pilots to report their own mishaps/ mistakes without repercussions in the context of improving overall safety. If an institution is really interested in safety data, anonymous is the way to go.