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.
Donna, a nurse in the Post-Anaesthesia Care Unit (PACU), heard people talking outside the unit after hours and went to find out what was happening. Plain clothes policemen were about to enter the PACU to interview a patient. Donna stopped them and asked them to discuss the request with the Admin Coordinator, as per policy. Good catch!
While working on 2B, Andrew noticed that the physician had ordered Amlodipine 200 mg – an unusually large amount for this medication. Andrew did not draw up the medication and sought clarification from the MRP. The order should have been for Amiodarone 200 mg so the MRP rewrote the order and Andrew administered the correct medication and dose. Good eye!
Jen, RN and Shelly, IR Booking Clerk are both part of the Diagnostic Imaging team. When Jen was consenting a patient for her thoracentesis procedure, the patient asked if she would also be receiving her liver biopsy but Jen saw only the thoracentesis for that day. The following day when clarifying procedures with Shelly, Jen inquired about the patient’s liver biopsy. Shelly had not received the order so Jen called the floor to have them enter the order and Shelly worked quickly to have the procedure booked within an hour of receiving the requisition. The floor was also requested to hold the patient’s anticoagulants so that the procedure could be completed that day. Great teamwork and patient advocacy!
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).