Congratulations to Emma Koivu – winner 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 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.

New winners will be randomly selected every quarter. Continue submitting your near misses for a chance to win! Near miss reports are submitted through the ILS. Click on the ‘safety reporting’ icon from your Novell home page or go to the iNtranet and choose ‘Safety Reporting’ under ‘Informational’.

Emma Koivu, Pharmacist, was awarded a certificate and gift card to the Thunder Bay Country Market for her ‘near miss’ submission to the Incident Learning System (ILS).
The details of the near miss are below:

• The patient, John Smith*, was admitted to hospital for a staged PCI after receiving two drug eluting stents
• John was started on clopidogrel (an antiplatelet to keep the blood slippery; among other medications) along with his home fluoxetine (an antidepressant/ anti-anxiety medication)
• fluoxetine and clopidogrel should not be given together because fluoxetine inhibits the conversion of clopidogrel to its active form which carries the risk of clopidogrel failure, stent thrombosis and heart attack
• The order was processed through the main pharmacy dispensary
• This very serious drug interaction was not flagged for the floor pharmacist (Emma) to follow-up with
• The pharmacist discovered the drug interaction when changing the order for fluoxetine on the floor the next day
• John was going to be discharged later that afternoon on this combination of medications
• If John had gone home on this combination, he would be at risk of very serious adverse events as outlined above
• Upon detection of this very serious drug interaction, Emma spoke with John and they decided on a course of treatment that aligned with John’s goals of care and avoided the drug interaction (continue fluoxetine, change clopidogrel to an alternative antiplatelet medication)
  
  *Patient information has been changed for privacy
  
  WORLD PATIENT SAFETY DAY
  Emma’s ‘Good Catch’ also highlights the important theme for this year’s World Patient Safety Day; ‘Medications without Harm’. The theme brings attentions to the fact that medications are the most widely utilized interventions in health care, and medication-related harm constitutes the greatest proportion of the total preventable harm due to unsafe care, let alone the economic and psychological burden imposed by such harm. For more information on the World Patient Safety Day, click here.
  
  For more information, contact Katherine Mayer, Patient Safety Specialist (mayerk@tbh.net).