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.
Karolyn, a 2C nurse floating on 1A, noticed that a wrong order sheet had been placed in a patient’s chart with an order for medications to be given that evening. She was concerned that the orders were meant for a different patient. After reading the progress note side of the order, she realized it did not make sense in relation to the patient’s current treatment plan and the note had stated assessments that were not done on the patient. She contacted the PA to clarify the orders and advised her she may have confused the order with that of a patient with the same name. Once clarified, Karolyn removed the order sheet from the wrong patient’s chart and the PA removed labels and proceeded to place proper patient’s labels on before filing it in the correct patient’s chart. Good catch!
While working on 3B, John started to assess a patient while referring to the SBAR and asked the patient if her right hip was in any pain, as that is what was documented on the SBAR, the admitting orders, and one note in the EMR. The patient, the patient’s daughter, and the nurse from the LTC home all stated it was the left hip that was painful, and John could also physically see shortening of the left leg. Additionally, he discovered the x-ray report noted the fracture on the left hip. John informed Admitting and correctly documented the left hip fracture. Great job!
Jessica works as a Medical Lab Technologist. Two different patients had bone marrow samples collected on the same day, and the specimens were sent down at the same time in separate bags. Both pathology requisitions had the same patient label on them. Jessica caught the labelling error in hematology prior to delivering the samples to pathology, and she was able to call up to the unit to have the nurse complete the correction of documentation before the samples were tested. Well done!
Thank you to all for your diligence and dedication to safety! Each recipient has been awarded a certificate and gift cards to local businesses to enjoy.
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).
