Quality and Patient Safety Begins with

Good Catch Program

Prepared by:Brenda Clemens, RN, BHA, CPHQDirector, Quality Management and Patient SafetyEmily Holman, MScClinical EpidemiologistTrudy Rhodes RNQuality Management Specialist

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High Reliability Organization Characteristics

• Sensitivity to operations - Commitment at all levels to quickly identify and fix actual and potential errors

• Reluctance to simplify - Do not accept simplistic solutions for complex issues

• Preoccupation with failure - Focused on predicting and eliminating errors rather than reacting to them

• Deference to expertise - Defer to person with the most knowledge

• Resilience - Able to quickly contain errors and improvise

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Builds Strong Culture of Safety

Commitment

Involvement

Communication & Trust

Learning and Reporting

Training

Responsibility

Reduced Patient Harm

Promotes Reporting of Near Misses

• A Near Miss is an unplanned event that did not result in

injury, illness, or damage – but had the potential to do so.

Only a fortunate break in the chain of events prevented an

injury, fatality or damage

• Near misses must be reported and taken as seriously

as errors reaching the patient, so steps can be taken to

evaluate processes and make improvements

• The Institute for Safe Medication Practices has reported

that 40% of clinicians either keep quiet or remain passive

after witnessing an improper patient care event to avoid

possible reprisals

Good Catch Program

Formal recognition program of staff and faculty who have taken action to prevent or mitigate harm from “close calls”, hazardous conditions, or errors.

Project Scope:1. Recognize efforts to report close calls or other patient safety

concerns2. Promotes transparency through dissemination of events and follow-

up actions3. Foster patient safety awareness4. Promote culture of safety5. Promote adoption of best practices to reduce potential of

preventable errors/harm

Good Catch Program

Project Champions:1. Dr. Robert Cherry2. Janet Rimicci

Project Members:1. Brenda Clemens2. Emily Holman3. Trudy Rhodes4. Loretta So5. Patricia Walker6. Sherry Watson7. Anet Sinanyan

Good Catch Award Process

• Staff enters Near Miss event into EVR system

• Manager determines that EVR qualifies for a Good Catch

• Select 2 Good Catches per month per facility for recognition

• Present certificates at Management Forum

• Present roaming awards for display in unit

• Post Good Catch Ribbon on unit PI Boards

• Announce winners at Nursing Quality/Leadership meeting

• Include in monthly UCLA Newsletter

• Present plaque to one Great Catch per year, per facility

Communication Plan

Thoughts and Input?