Center for Improvement in Healthcare Quality Newsletter
February 2022

CIHQ-ARS Blog

Making the Good Catch

By: Gina Miller
As you prepare your medications for your post-operative patient, you pull the patient’s Lovenox from the Automated Drug Cabinet storage bin and head to the patient’s room. Checking your 5 rights before administration, you notice that the syringe is marked with 80mg rather than the usual 30mg. Carefully checking the patient’s order, 30mg is clearly ordered. When you check the drawer, both 30mg and 80mg pre-filled syringes are in the bin. Wow, good catch! You stopped an error from occurring because you practiced your 5-rights (or 7- or 9-rights) before administering the medication. Pat yourself on the back. You just made a good catch. Switch out the syringe and go on with your busy shift - right?
Wait one minute. Why were the two different types of syringes stocked together? Is the next shift going to be as careful and administer the right dose? Preventing future harm due to avoidable events is a primary goal of safety event reporting. Organizations should prioritize staff reporting of such events. In the scenario above, both types of syringes had inadvertently been placed in the same bin rather than their respective bins. When pharmacy was notified, it was discovered that 80mg syringes were stored in the incorrect bin in pharmacy. They were not scanned when placed into the drug cabinet due to a downtime. The holes in the swiss cheese had lined up and the final check prior to administration had prevented the error from occurring. Had the event not been reported and immediately investigated, significant risk for multiple errors would have occurred.
Staff tend to view good catch and near miss events as a routine part of their job rather than a source of data to improve patient safety and the quality of care. Good catches and/or near misses occur up to 100 times more frequently than Serious Events. Reporting and analyzing them can reveal gaps in the organization’s processes so risk reduction strategies can be proactively implemented to improve patient safety. Let’s distinguish between a great catch and a near miss and explore best practice around developing a reporting culture.
A good catch is an action-oriented program that implies somebody did something positive to prevent something bad from happening. I recognized an unsafe condition, action, defect, or flawed piece of equipment and I acted to prevent an event from occurring. On the other hand, a near miss is an incident that did not result in injury illness, or damage – but given a slight shift in time or position, damage or injury could have occurred. Here is a practical example…fire precautions are improperly taken during a surgery prep and a spark ignites a Duraprep soaked gauze in the kick-bucket which is immediately extinguished without causing harm to the patient or staff. This is a near miss – it is reactive. No one was injured but it certainly had potential to be a disaster. A good catch in the same scenario would be the recognition that there is a potential for ignition due to not removing the kick-bucket from the area prior to surgery. Staff bring this concern to a safety huddle and the practice is changed to always remove the used prep materials from the room before beginning the procedure. This is a good catch – it is proactive. Both incidents should be equally reported, investigated, and analyzed.
Organizations need to be intentional about encouraging and incorporating good catches into their safety event reporting system. To encourage reporting of events organizations should:
  1. Garner Leadership Support: When talking to senior leaders, it’s important to present baseline reporting data and to help them understand how increased near miss/good catch reporting can translate into fewer adverse events.
  2. Make it Easy to Report: Make reporting user-friendly, fast, and easy. The time it takes to report is a significant barrier to reporting, especially if no patient harm occurred.
  3. Safe to Report: Create a nonpunitive environment in which staff feel secure and comfortable to report safety concerns.
  4. Tell Me a Story: Develop a system to provide feedback and advance meaningful improvements stemming from safety event reporting. Using storytelling as a communication strategy at huddles or staff meetings is a powerful communication tool to understand, remember, and accept new ideas.
  5. Reward Staff: If fiscally possible, reward staff for identifying good catches. Whether it be on an individual or unit basis, find a way to celebrate good catches that impact patient safety.

References

Institute for Safe Medication Practices. (2017). Telling true stories is an ISMP hallmark. Available from ismp.org
Wallace, S., Mamrol, C., and Finley, E. (2017). Promote a culture of safety with good catch reports. Pennsylvania Patient Safety Advisory 14(3). Available from patientsafety.pa.gov
View Other CIHQ-ARS Blog's at CIHQ-BLOG.org