1. Quality and Patient Safety Begins with Good Catch Program Prepared by: Brenda Clemens, RN, BHA, CPHQ Director, Quality Management and Patient Safety Emily Holman, MSc Clinical Epidemiologist Trudy Rhodes RN Quality Management Specialist

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3. High Reliability Organization Characteristics Sensitivity to operations - Commitment at all levels to quickly identify and fix actual and potential errors Reluctance to simplify - Do not accept simplistic solutions for complex issues Preoccupation with failure - Focused on predicting and eliminating errors rather than reacting to them Deference to expertise - Defer to person with the most knowledge Resilience - Able to quickly contain errors and improvise 3

4. Builds Strong Culture of Safety CommitmentInvolvement Communication & Trust Learning and Reporting Training Responsibility Reduced Patient Harm

5. Promotes Reporting of Near Misses A Near Miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage Near misses must be reported and taken as seriously as errors reaching the patient, so steps can be taken to evaluate processes and make improvements The Institute for Safe Medication Practices has reported that 40% of clinicians either keep quiet or remain passive after witnessing an improper patient care event to avoid possible reprisals computer error

6. Good Catch Program Formal recognition program of staff and faculty who have taken action to prevent or mitigate harm from “close calls”, hazardous conditions, or errors. Project Scope: 1.Recognize efforts to report close calls or other patient safety concerns 2.Promotes transparency through dissemination of events and follow- up actions 3.Foster patient safety awareness 4.Promote culture of safety 5.Promote adoption of best practices to reduce potential of preventable errors/harm

7. Good Catch Program Project Champions: 1. Dr. Robert Cherry 2.Janet Rimicci Project Members: 1.Brenda Clemens 2.Emily Holman 3.Trudy Rhodes 4.Loretta So 5.Patricia Walker 6.Sherry Watson 7.Anet Sinanyan

8. Good Catch Award Process Staff enters Near Miss event into EVR system Manager determines that EVR qualifies for a Good Catch Select 2 Good Catches per month per facility for recognition Present certificates at Management Forum Present roaming awards for display in unit Post Good Catch Ribbon on unit PI Boards Announce winners at Nursing Quality/Leadership meeting Include in monthly UCLA Newsletter Present plaque to one Great Catch per year, per facility

9. Communication Plan

10. Thoughts and Input?