Congratulations to Taylor Dewal, Emily Bernie and Alison Lester – our winners of the quarterly ‘Good Catch’ Awards!  

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 co 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.

Registered Respiratory Therapist (RRT), Taylor was working in Critical Care when a student Respiratory Therapist notified her of a patient who had his non-invasive mechanical ventilation (NIMV) removed.  Taylor reviewed the chart and did not see an order for removal of the NIMV.  She confirmed with the physician that the code status had not changed and there was no order to remove it.  Taylor advocated for the patient to remain on the NIMV as the patient was displaying signs of respiratory distress with each assessment and agreed he was more comfortable on the machine. The physician then wrote orders for the patient to remain on the NIMV overnight.  Excellent patient advocacy!

While working on 2B, Emily notified Nutrition & Food Services that the patient had not received extra sauce with her meal, which was required with the minced and moist diet due to choke and aspiration risk. Good catch!

Alison was working as the pharmacist on 2C and while checking order sheets, noticed that the wrong patient label was attached to an order for a different patient.  Both patients had admission orders for the same unit and were assessed by the same physician around the same time.  The error was caught and corrected before any medications were administered to either patient. Great catch!

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 this summer.

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).