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’
- An opportunity to prevent harm to patients in the future
- 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’
- Know your policies
- Utilize the Incident Tracking Reporting System
- 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.
- Identify how the risk was discovered and mitigated
- Verbally notify your Manager
- 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
The more we report, the more we learn.
A near miss today could prevent an occurrence tomorrow.
See one. Report one.