12/8/2015 The “Good Catch” Program Vereline Johnson, MSN, RN Patient Safety Officer Amy Cutler, PhD, RNC, NNP, PNP.

Slides:

Advertisements

Similar presentations

Critical Event Review (Root Cause Analysis)

Advertisements

2014 National Patient Safety Goals

An Imperative for Performance Improvement

The Patient Safety Challenge in the UK Dr Kevin Cleary Medical Director National Patient Safety Agency.

Conducting Patient Safety Rounds with Staff. First Steps Set the stage –Unit and Hospital Leadership Support –Identify a “champion(s)” for each unit where.

Interprofessional Students Seek and Find Safety Hazards at the Bedside Gretchen Gregory, MSN, RN, Carla Dyer, MD, Sue Boren, PhD; Doug Wakefield, PhD Sinclair.

Risk Management / CQI Nutr 564: Management Summer 2002.

MINIMISING MEDICATION ERRORS. Medication Errors  Aims. –To discuss the number and types of medication errors and the ways in which they may be minimised.

Dr. ABDULLAH ABDU ALMIKHLAFY Assistant professor & Head of community medicine department Presented By University of Science & Technology Sana’a – Yemen.

Just Culture Application Consoling Employees

Trigger Tools 4 th February 2009 Presenter: Liz Baines.

Leadership, Management, and Followership

Safety Huddle improves Safety Culture

Conducting A Root Cause Analysis

Systems for Safety June Much has Been Done … Trend in Age-Adjusted 30-Day In-Hospital Death Rate Excludes NL, QC, BC.

Professional Advancement Model for Nurses Office of Clinical Practice & Professional Development Copyright 2009.

© Copyright, The Joint Commission 2013 National Patient Safety Goals.

by Joint Commission International (JCI)

NORTH AMERICAN SAFETY CHECKLIST – SB 158. Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc. Presented By:

Farmleigh House, Dublin, June 29-30, 2006

JCAHO UPDATE June The Bureau of Primary Health Care is continuing to encourage Community Health Centers to be JCAHO accredited. JCAHO’s new focus.

Safety: It’s Everybody’s Business Virginia Ingram, MSN, RN Patient Safety Officer University of Mississippi Medical Center.

Department of Quality and Regulatory Affairs Barbara Ann Karmanos Cancer Center 2009 The Karmanos Cancer Center Quality, Patient Safety, and Performance.

Unit 1a: Health Care Quality and HIT Introduction to QI and HIT This material was developed by Johns Hopkins University, funded by the Department of Health.

PROPRIETARY NAME EVALUATION AT FDA Jerry Phillips, RPh Associate Director for Medication Error Prevention Office of Drug Safety December 4, 2003.

Occurrence Reports. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs.

CLABSI Supplemental Call Series Best Practices: How Successful Units Engaged Their Senior Executive Leaders October 18, 2011 Presenters: Jonathan Kling,

Improving Employee Safety at Spartanburg Regional Denise Hollis, RN, COHPM Mike Arntz, CHSP.

Delivering a Healthy WA Minimising Medication Errors: A new approach to medication safety WATAG Seminar Nick May Staff Development Educator Royal Perth.

Engaging the Workforce in Key Projects Leadership Symposium April 19, 2011 Linda Whaley, MS, RN, Vice President Clinical Services Amy Stark MSN, RN-BC,

Good Catch Awards These awards are for the purpose of encouraging contributions to the Patient Safety net regarding averted medication errors. When you.

The Comprehensive Unit-based Safety Program (CUSP)

Gripesand Performance Improvement In Residency Auxford Burks, MD Albert Einstein College of Medicine Department of Pediatrics/ Jacobi Medical Center.

Developing User Accepted Asset Management Networks and Processes Bob Mahaney, CPPS Mgr, Program Accounting & Finance MD Anderson Cancer Center.

Peer Outreach Team We are a diverse group of 33 young people aged between 15 – 25 from different boroughs around London, who help the GLA engage with young.

Medication Error Reduction Principles in Practice Copyright © – Academy of Managed Care Pharmacy (AMCP)Slide 1.

Carilion Clinic, Office of Sponsored Projects Frequently Asked Questions Pre-Award Procedures For Principal Investigators.

Getting to Zero and Sustaining Success: The Virginia Experience Barbara Brown, Vice President Virginia Hospital and Healthcare Association May 8, 2012.

Occurrence Reports. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs.

CONTEMPORARY IMAGE OF PROFESSIONAL NURSING. Core statement according to Royal College of Nursing 2003 “Nursing is the use of clinical judgment in the.

National Patient Safety Goals (NPSGs)

© Copyright, The Joint Commission 2015 National Patient Safety Goals.

La Salle University Undergraduate Nursing Programs Quality and Safety Education for Nurses (QSEN)

© Copyright, The Joint Commission 2014 National Patient Safety Goals.

Quality and Patient Safety Begins with Good Catch Program Prepared by: Brenda Clemens, RN, BHA, CPHQ Director, Quality Management and Patient Safety Emily.

Incident Reporting To every patient, every time, we will provide the care that we would want for our own loved ones.

PROMOTING PATIENT SAFETY BY PREVENTING MEDICAL ERRORS Safety concerns facing health care systems today.

National Patient Safety Goals 2008 T he University of Toledo Medical Center Toledo, Ohio.

RISK MANAGEMENT. PURPOSE: Risk Management is the process of making and carrying out our decisions that will minimize the adverse effects of accidental.

Oncology Nursing Coastal Carolina Chapter Oncology Nursing Society.

RISK MANAGEMENT Kansas Spine & Specialty Hospital Annual Competency 2016.

Hospital Accreditation Documentation Process & Standard Requirements

Kelli Pirruccello, BSN, RN. Background  Monitoring systems are intended to increase patient safety in the hospital setting by quickly alerting caregivers.

The Need to Improve Quality of Nursing care, Patient’s Safety and Evidence-Based Practice in Saudi Arabia Dr Abbas Al Mutair Ph.D, MN, BN, CCN Post Grad.

Texas Center for Quality and Patient Safety Dennis Cook, MSN, RN, CPPS Senior Director, Texas Center for Quality and & Patient Safety Texas Hospital Association.

Quality & Safety Candace C. Cherrington, PhD, RN Associate Professor.

Performance Improvement Model Implications for Practice

Specialist of Clinical pathology Patient safety officer

Healthcare workers report some of the highest injury rates in the nation, and those injuries come at a price beyond the workers' wellbeing. In 2011,

Research Implications: Clinical Implications:

Health Care Injuries.

2017 National Patient Safety Goals

ALLEGATIONS OF ABUSE Internal Occurrence Reporting and Investigation.

Organization Wide Daily Safety Huddle

Ambulatory Voice Of Nursing The Orange County Journey PURPOSE PROCESS

Structures, Process and Outcome

More is Better: Engaging Staff to Improve Event Reporting in Ambulatory Care Mara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ Patient Safety & Quality RN Melissa.

The Science Behind Falls Management

Presentation transcript:

12/8/2015 The “Good Catch” Program Vereline Johnson, MSN, RN Patient Safety Officer Amy Cutler, PhD, RNC, NNP, PNP

Background Developed by Dr. Robert Massey, Director of Clinical Nursing and The University of Texas M. D. Anderson Cancer Center in Since 2005, M. D. Anderson has received over 82,000 reports of events before they could reach the patient. The program is becoming a national model for development of similar systems. 2 12/8/2015

Purpose Encourage staff to report potential patient safety errors, commonly referred to as “near misses” or “close calls,” that they identify and correct them as part of their daily practice. Reporting such instances allows for analysis of systems and factors that may contribute to errors. 3 12/8/2015

Overall Goal To change the culture of error reporting by shifting the emphasis from the negative implication of a “near miss” or “close call” to focus positively on employees’ actions to identify and prevent potential errors with medications, equipment, and patient care. 4 12/8/2015

NICU Good Catch Program 5 12/8/2015

Discovering the Challenge Some shocking numbers Pediatric patients experience 3 times more potentially harmful errors than the general adult population. 1.9% infants experienced serious harm, causing life threatening or significant damage from errors (VON) Medication errors account for more than 18% Neonates rank among the highest at risk groups for healthcare associated infection 6 12/8/2015

Discovering the Challenge Estimated that nurses only report 5% of significant errors: Fear Disagreement over if an error really occurred Administrative response Reports too time consuming 7 12/8/2015

NICU Good Catches - 90 Medication Order Error (9) Medication Dispensing Error (23) Missed/Failed Treatment (9) Transcription & Communication Error (17) Procedure Issues (8) Infection Control (1) Equipment/Devices (11) Fall Prevention (1) Other (11) 8 12/8/2015

Achieving Change Good Catch now administrated by staff Good Catches moving beyond the obvious to those that require some thought Everything nurtured, will grow.

Accept the Challenge We have accepted the challenge…will You? 10 12/8/2015

Process for Reporting a Good Catch 1.Recognize/discover a potential patient safety problem and take corrective action. 2.Complete the “Good Catch Award Submission Form.” 3.Send or fax the completed form to the Performance Improvement Department /8/2015

Good Catch Rewards Good Catch Award Certificate. Coupon redeemable for a drink or ice cream treat in the Tuscan Sun restaurant. Consideration for the Good Catch of the Quarter Recognition. Personal satisfaction for contributing to improved patient safety /8/2015

Certificate 13 12/8/2015

Coupon 14 12/8/2015

Examples of a Good Catch Discovering an expired medication prior to administration. Preventing a patient fall. Recognizing the label on an IV infusion does not match the pre-printed information on the bag. Discovering a sterile dressing package is torn/compromised /8/2015

Summary “We’re trying to create a fair and supportive culture in which nursing staff feel empowered to identify opportunities to improve patient safety and eliminate any fear of reporting.” Barbara Summers, Ph.D., Vice President and Chief Nursing Officer, The University of Texas M. D. Anderson Cancer Center /8/2015