The Good Catch Program will focus on ‘Near Misses’

Near misses are caused by the same kinds of workplace hazards that cause actual accidents

• A near miss is a potential hazard or incident in which no property was damaged, and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as close calls, near accidents, or injury-free events.
• Near miss can occur with:
  • Mishandling of chemicals or hazardous materials.
  • Equipment malfunctions.
  • Slips, trips, and falls without injury (narrow escapes)
  • Signage-related incidents.

According to the Institute of Medicine, a near miss is “an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation.”

Types of ‘Near Misses’

• Good Catch: Describes a situation where an incident of any type was avoided. A near miss event that did not reach the patient because of the thoughtful actions of an employee. 
• Good Save: A reportable incident that reached a patient with minimal to no harm due to quick/thoughtful actions of an employee.
• Our goal is to minimize good saves and convert into good catches.

Why we focus on ‘Near Misses’

1. An opportunity to prevent harm to patients in the future
2. A method for revealing process and system vulnerabilities
   A near miss is a lesson learned

What do ‘Near Misses’ look like?

• Fall Risk patient was left on the stretcher without the siderails up
• A nurse passing out her scheduled medications and right before she was about to give a patient their pills, she realized she grabbed the wrong medication when going through the ‘five rights’
• Two patients with the same last name, but different spelling was in the pre-op area at the same time.  Using the two approved patient identifiers the nurse was able to distinguish between the two patients
• During the “time-out” process in the procedure room it was discovered the incorrect eye was marked
• Incorrect medication orders
• Wrong labeling or patient identification on specimens
• Missed information
• Insufficient follow-up
• Patient consent inconsistencies

Reporting a ‘Near Miss’

1. Know your policies
2. Utilize the Incident Tracking Reporting System
3. Record as many details that contributed to the risk as possible including but not limited to lighting, time of day, staffing concerns, legibility of handwriting, language barriers, etc.
4. Identify how the risk was discovered and mitigated
5. Verbally notify your Manager
6. Once submitted the report will be reviewed by the Manager, Quality team and AE Engagement Committee

Using SAFETY ZONE to report a ‘Near Miss’

• Click [Submit Event]
• Select form [Patient Occurrence]
• Complete demographic questions [What is being reported?]
  • Select [Near Miss]
  • Event type: Select [Near Miss]
  • Sub event type: Select from list
• Continue to complete form
• Add attachments as needed

We will track our progress

• Near Misses will be used internally to improve care
• Progress will be shared throughout Covenant Physician Partners enterprise-wide (e.g., huddles, newsletter, rounding, training sessions, etc.)

The Good Catch Award

• The Good Catch Award is for any staff member who noticed something and proactively did a safety check to improve worker or patient safety. It recognizes staff who caught something that others didn’t and escalated to make sure the patient is safer and cared for.
• The Good Catch Award Rules
  • Eligibility: Quarterly review of all practice and ASC facilities reporting near misses using Safety Zone
  • Celebrations: The top 3 facilities with the most reported* and implementable action plan will be celebrated with breakfast and a Good Catch Award
  • Competition runs April 1 – June 30 and then quarterly thereafter* Normalized by total volume

Good Catch