1. 12/8/2015 The “Good Catch” Program Vereline Johnson, MSN, RN Patient Safety Officer Amy Cutler, PhD, RNC, NNP, PNP

2. Background Developed by Dr. Robert Massey, Director of Clinical Nursing and The University of Texas M. D. Anderson Cancer Center in 2005. 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

3. 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

4. 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

5. NICU Good Catch Program 5 12/8/2015

6. 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

7. 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

8. 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

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

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

11. 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. 11 12/8/2015

12. 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. 12 12/8/2015

13. Certificate 13 12/8/2015

14. Coupon 14 12/8/2015

15. 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. 15 12/8/2015

16. 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. 16 12/8/2015