Enlist staff to find system flaws before errors occur
Reward staff for interventions that prevent mistakes
Do clinical staff feel truly comfortable reporting near misses and potential errors at your organization? The answer could have a major impact on patient safety.
At M.D. Anderson Cancer Center in Houston a "Good Catch" program was created with the goal of identifying safety issues and reporting so solutions to potential errors can be developed and implemented. Clinical nurses play a key role in this, says JoAnn Mick, PhD, RN, associate director of nursing research.
The program uses a baseball theme to organize units as teams in one of four "divisions," with three divisions comprising 14 inpatient units and a fourth division scheduled for implementation. "Each unit chose a team name and some of the teams have developed team logos," says Mick.
One goal of the program was to increase the number of safety reports submitted to the Close Call Reporting System (CCRS). The strategies implemented include:
- Changing terminology related to nurses' identification of potential errors from "near miss" or "close call" (which acknowledge error) to "good catch" (which acknowledges practice).
- Implementing an "end-of-shift safety report" to help nurses identify concerns related to patient safety that occurred during the shift and to provide a reminder to submit a CCRS report to document the nursing intervention.
- Promoting incentives such as "safety awards" sponsored by executive leadership to acknowledge individual nurses.
Each close call report that identifies a Good Catch by a team member results in one point for the team engendering friendly competition between the team and divisions. The team that submits the greatest number of close call reports during a six-month "game" is recognized and awarded with a pizza party. "MVPs" are identified on each unit and receive a patient safety award certificate.
The vice president and chief nursing officer in the division of nursing visits each unit after they have joined the program, and distributes Good Catch pins to participating team members. Units prepare patient safety storyboards and share information about the types of Good Catches recorded in their end-of-shift safety report logbooks.
Initially, many of the teams expressed concern that a high number of potential error reports would "look bad" for the unit. "Reinforcement was provided to assure teams that higher numbers of submitted reports supported a greater focus on patient safety," says Mick.
Also, because nurses historically had submitted reports only when an error had occurred, a change in thinking was required to understand that nurses should report interventions that prevented an error.
"Nurses identify and correct errors as part of their daily practice. But these fixes are not often reported so that systems issues can be identified and addressed," says Mick. "Close-call reporting provides nurses with the opportunity to document their important role on the front line of patient safety."
Each week the numbers of submitted reports are tallied, with scores e-mailed to team representatives. Scoreboards are posted on nursing units and are included in the on-line weekly nursing newsletter to recognize the teams and division that submitted the most reports.
In addition, a weekly summary of the types of reports submitted and action plans for items that require follow-up are e-mailed to teams. "This verifies that nursing time used to enter reports is a worthwhile investment of time and effort," says Mick. Since the Good Catch pilot was launched in December 2005, more than 10,000 reports have been submitted from participating units.
Good Catch themes have included: medication dispensation and labeling, transcription, communication, equipment, policy issues, clinical procedure issues, and fall prevention. "Reported concerns are addressed with the assistance of quality improvement, and are reported back to the units," says Mick.
One concern involved nurses continually changing one of the intravenous tubings due to a leaking port. "The manufacturer was contacted and a quality review of the manufacturing process identified a problem with one of the welds," says Mick. "They revised the process and are now producing tubing that doesn't leak. The company also sent a thank you letter to the nurses for reporting the problem."
Another potential error was identified on an order set that listed medication names with blanks for the physician to fill in dose per unit of measure. All medications were to be ordered in milligrams, except for one in the middle of the page. "When filling out the order set, a physician calculated and ordered all of the medication doses in milligrams," says Mick. "The potential error was caught by the nurse and pharmacist and was prevented." The medication that requires a varied dosage/unit is now highlighted on the order set.
At Spectrum Health in Grand Rapids, MI, a Good Catch program catches potential errors before they reach the patient. "The system is proactive in identifying system flaws and supporting a non-punitive culture of safety," says Sylvia Baird, manger of patient safety.
The program began in 2004, with staff asked to report near misses on index cards with fish pictured, called Good Catch cards. The data was entered in an Excel database used to identify trends or patterns that could be potentially unsafe for patients.
As a result of staff reports related to scheduling and the paper medication administration record, system changes were made in the way procedures were scheduled and the development of the electronic medical record for medication administration.
At the same time, though, incident reports were being filled out separately. "People started saying, how do we put the two of them together? This was difficult to do, since both the incident reporting process and the Good Catch program were submitted by paper, and sent to two different areas of the hospital," says Baird.
In 2005, the hospital's incident reporting system switched to an electronic system, but the Good Catch program was still paper-based. In November 2006, Good Catches were converted to the electronic system and made part of the organization's incident reporting process. Staff can go onto the web page, choose whether they want to report an incident or near miss, and electronically enter the data.
"We are very excited about being on the same page. We are using the same headings and descriptions when either an incident report or Good Catch is completed," says Baird.
Because of the standardization, reports can be requested that include both Good Catch data and incident report information, such as identifying reported duplicate medication orders. "We then can use that information to identify where process flaws may occur, and then make system improvements," says Baird.
When a staff member reports a Good Catch, these steps occur:
- The staff member answers the questions "What is the issue?" "What contributed to it?" And "What recommendations do you have?"
- The nurse manager is alerted by e-mail that the report was filled out "so they can be reviewing that within 24 hours of being reported vs. waiting for the manual process of reviewing the data," says Baird. "If it relates only to their area, they can implement changes on their unit immediately."
To encourage staff to report near misses, there is a recognition program called "What a Catch!" with near misses reviewed to see which ones had a significant impact in preventing harm. At an annual banquet, one individual is recognized and given a plaque for their role in system changes that were made to promote patient safety.
A recent example involved a staff members reporting that patients in the adult critical care unit were experiencing low blood sugars. Upon further investigation, the low blood sugars were correlated with patients that were receiving a new type of insulin during the evening and then having their nutritional intake being held for procedures the following day. The staff person collaborated with pharmacy and developed a process to flag this potential medication safety issue.
Now that the data are easier to collect and collate, quality professionals can go in and query the database looking for a specific word or phrase, such as "duplicate orders" or "scheduling issues."
"Before, even though we had an Excel database, there was no connectivity to them both," says Baird. "Now the quality professional can analyze, trend, and track the information, and use those critical thinking skills to go and hone in on the system issues involved."
[For more information, contact:
Sylvia K. Baird, RN, BSN, Manager, Patient Safety, Spectrum Health Hospital, 100 Michigan St. NE, Grand Rapids, MI 49503. Telephone: (616) 391-2078. Fax: (616) 391-2119. E-mail: [email protected]
JoAnn Mick, PhD, RN, Associate Director, Nursing Research, University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 82, P4.3127, Houston, TX 77030. Telephone: (713) 792-6660. Fax: (713) 792-1883. E-mail: [email protected].]
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