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.
While working in the ED,nurse Alyssa prepared medication for her patient as ordered. She hung Piptaz at the bedside, connected a line to the patient’s IV saline lock, verified the patient’s wristband for ID and allergies, and confirmed that the patient did in fact have an allergy to the medication. Upon this discovery, she did not administer the medication and immediately disconnected the line. She cleansed the port, reconnected Ringer’s Lactate, and notified the resident and ED physician of the noted allergy. Great catch!
Devan, a Nuclear Medicine Technologist, was prepping a patient for her gastric emptying study. He had just taken the patient’s blood sugar when suddenly the patient stated that she thought she was going to faint and within seconds, slumped over in the chair. Devan and the patient’s mother caught the patient and held her upright in the chair to maintain a clear airway for the duration of the episode. After the patient regained consciousness within 20 seconds with no apparent ill effects, Devan continued to monitor her throughout the next several hours with no further concerns or issues. Well done!
2C Nurse Camryn was working with a patient who was to be transferred to UHN the following day for a coronary artery bypass grafting (CABG). When she called ORNGE to find out the flight information, ORNGE had no patient transfer information for this specific patient and no flight plans had been made. The patient’s most recent Provincial Transfer Authorization had expired and without it, there would be a delay in transferring the patient. Camryn submitted a new authorization request after the cut-off time for next-day transfers but explained the urgency of transferring this patient to prevent a delay in the scheduled CABG procedure. The next morning the patient was picked up by ORNGE and travelled to Toronto for his procedure. Excellent work!
Thank you to all for your diligence and dedication to safety! Each recipient has been awarded a certificate and gift cards to a local business 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 Specialist (terry.fode@tbh.net).
