How many times have you heard things like this during your healthcare career?
Read on to learn more about how your organization can improve patient safety with a good catch program and tips on getting started.
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“That was a close one!”
“Today must be that patient’s lucky day.”
If you’re like the majority of those working in healthcare, chances are you’ve likely experienced or at least heard about an occurrence that could have been devastating but was prevented thanks to timely
Whatever you call it, these events which do not result in patient harm often happen many times before an actual harmful event takes place. Therefore, good catches and near misses can be seen as learning opportunities to better understand root causes and process gaps and implement changes to prevent them from happening again.
A good catch program is an action oriented program that uses incentives to encourage an increase in near miss reporting. By implementing a good catch program, healthcare organizations can reframe event and incident reporting as a proactive way to prevent harm and enhance quality of care.
How to Improve Patient Safety with a Good Catch Program
“Things really could’ve been bad!”
are known by many terms: good catch, near miss, close call, or even the colloquial “close shave.”
However, near misses, regardless of severity, are historically underreported in the healthcare space and beyond. Mass underreporting is a cultural byproduct and typically happens when trust
Improve Patient Safety with a Good Catch Program
levels are low and employees fear the consequences of reporting an event, even if it’s a near miss.
What’s a Good Catch?
A good catch program is an incentive based program that fosters a culture of reporting by training and encouraging staff to recognize and report risk, and reframing reporting in a positive light. Even the term “good catch” itself has encouraging undertones. It implies that someone did something positive to prevent something negative from happening. It encourages employees to think of good catches like this: “I identified an unsafe condition, action, defect or flawed piece of equipment and I acted to prevent an event from occurring. I caught it early and avoided harm.”
Consider this real life anecdote. A patient care assistant in a Pennsylvania hospital was transferring a patient into a bed when the bed moved, despite the wheels being locked. Although the patient was not harmed, the patient care assistant raised the issue during one of her unit's daily safety huddles.
That’s because good catches typically occur as much as 100 times more frequently than adverse events and can reveal gaps in an organization’s processes and systems. When healthcare employees report good catches through an incident reporting system, organizations can analyze these events to identify their causes and proactively implement strategies to reduce risk and prevent related events from reoccurring.
A good catch in healthcare is recognized as an employee interception of a potential safety event before a patient is harmed. Not only do good catches break the cycle in the chain of events that could lead to patient harm or even death, but they also present healthcare organizations with opportunities for learning to reduce harmful incidents.
This led to an inspection of all the beds on the unit. Facility personnel discovered that the wheel locks on 60% of the beds needed repair; these findings prompted a hospital wide wheel lock inspection and repair. The patient care assistant was later recognized by the Pennsylvania Patient Safety Authority in their 2017 "I Am Patient Safety" campaign.
When a company’s safety culture includes encouragement and recognition for employees who see something, say something, and do something to prevent events from occurring, the company has implemented a good catch program.
Just as with other safety activities, years of practice have provided insight on near miss management.
6 Characteristics of an Effective Good Catch Program
Good Catch Program Outcomes, By the Numbers Through good catch programs, employees gain a further sense of purpose, as they are empowered to take proactive measures to potentially prevent patient harm. Not only are these programs incredibly effective in improving workforce morale, but they also improve patient safety by increasing the volume of near miss reports.
Although reporting, investigating, and correcting near misses is not a regulatory requirement, it is increasingly becoming common practice in the healthcare space.
One great source of such insight is research from Wharton Business School. After conducting over 100 interviews of employees at all levels of
In 2017, 45 hospitals participated in the American Data Network PSO’s (ADNPSO) Good Catch Campaign. Participating organizations saw a 47% increase in near miss reporting; each hospital reported an additional 246 near misses per month on average. Moreover, 63% of organizations saw a decrease in overall patient safety incidents related to near miss corrective actions, illustrating the transformative power of good catch programs.
Fast and simple reporting processes exist: For a good catch program to be successful, anyone must be able to report a good catch. A clear and simple procedure for reporting near misses is key to increasing the likelihood of participation in a good catch program.
Companies that manage near misses effectively properly distribute appropriate information about the incident by:
•
Incident reporting software like ours automates these burdensome tasks and does so immediately upon the completion of an event form.
• Routing the information to all appropriate points of contact
• Transferring the information quickly
Communicating the information in a useful and understandable format
various Fortune 500 companies, Wharton researchers identified several hallmarks of an effective near miss program. Among them include: “Good catch” is clearly defined: One common thing that effective good catch programs have in common is that the term “good catch” (or “near miss”) is broadly defined to include not just events, but also unsafe conditions and behaviors. Once clearly defining the term “good catch,” healthcare organizations should communicate its meaning with its entire workforce.
User friendly incident reporting systems, like Performance Health Partners’, which are readily available and responsive on any mobile device, facilitate the reporting process and encourage near miss reporting.
Program is well communicated: Good catch programs need to be clearly communicated, so employees are absolutely certain the information they report will not result in reprimand. “No penalty” reporting must be stated, reinforced, and consistently reiterated from the very top.
Near misses are prioritized and relevant information is distributed: When near misses are reported, they must be prioritized.
Causes are determined and corrective solutions are implemented: As near miss information is tracked and trends are analyzed, the root cause of these events must be determined so that appropriate interventions can be developed and implemented to prevent related events from reoccurring.
Solutions are continuously monitored: The final phase of a good catch program is monitoring the corrective actions taken to ensure that they effectively address the cause of the near miss(es). Sometimes, remedying one issue can create other unforeseen hazards. Thus, monitoring and managing changes and ensuring no new hazards result from them is critical to the success of a good catch program. Additionally, it’s essential to communicate the information collected and actions taken so employees feel that their report was beneficial in improving patient safety.
Implementing an effective good catch program begins by reviewing trends in system data and defining a goal for increasing reporting over time. Isolating good catch data by month can be helpful in making this goal a reality. Next, consider ways to improve current reporting processes. For organizations that use incident reporting software, this includes adding good catch reports into daily workflows. It is important to obtain senior leadership support during this process by demonstrating expected outcomes. Executing a recognition and rewards program for those who submit reports encourages employees to submit more near miss reports.
How to Start a Good Catch Campaign
Lastly, designate a skilled committee or team to manage the program and develop an action plan.
For a complete guide on how to start a good catch program to improve patient safety at your healthcare organization, download our free toolkit,
complete with sample goals and a checklist of tasks to execute to ensure your good catch program is a successful one.