Congratulations to the winners of the quarterly ‘Good Catch’ Awards, Karen Boyes and Chelsea Hurd.
Good Catch Awards highlight individuals, groups or departments who demonstrate their commitment to keeping patients safe by reporting a near miss. A ‘good catch’ (or near miss) is an event or situation that could have resulted in harm, but did not reach the patient because of chance or timely intervention. Reporting these events can help to identify gaps in order to prevent future adverse events from happening.
Karen was working in the Cancer Centre when she received a dose of carboplatin at the Pharmacy with an incorrect label. The dose was not within 10% of the calculated dose and would, therefore, be unsafe to administer. An independent double-check was completed with another nurse. Karen then called the pharmacist to request that the chemotherapy be remixed to ensure proper dosing and labelling. Great catch!
While working on 2C, day nurse Chelsea followed a physician’s orders to discontinue oxygen and discharge a patient home. However, it was noted that the patient still required oxygen. Chelsea completed a walking test without oxygen, and the patient continued to desaturate, after which she notified the physician. This led to the discharge being put on hold until RT could re-assess. It was determined that the patient qualified for home oxygen. Chelsea used great nursing judgment in advocating for a delayed discharge. Good initiative!
Thank you to both for your diligence and dedication to safety! Each recipient has been awarded a certificate and gift cards to local businesses.
New winners will be selected every quarter. Continue submitting your near misses for a chance to win! Near miss reports are submitted through the Incident Learning System (patient safety incidents). Click on the ‘safety reporting’ icon from your Novell home page, or go to the iNtranet and choose ‘Safety Reporting’ under ‘Informational’.
For more information, contact Terry Fodë, Patient Safety Improvement Specialist (terry.fode@tbh.net).