By Susan Y. Allen, American Data Network PSO
American Data Network PSO’s (ADNPSO) Good Catch campaign is transforming the way Arkansas hospitals approach patient safety. Frontline staff, managers and senior leaders in 43 facilities are discovering the value of a traditionally under-reported type of patient safety event – the “near miss.”
Good Catch promotes a proactive mindset by empowering staff to speak up when potential risk is identified, because a near miss reported today could prevent an error tomorrow. Close calls are free lessons that reveal weaknesses and strengths in processes while accentuating opportunities for improvement.
Prior to the campaign’s January launch, ADNPSO provided training related to near miss reporting and an online tool kit featuring a Blueprint for Success. The PSO releases new resources, including infographics and tip clips, quarterly. At the end of July, hospitals had collectively reported over 2,000 near misses and reinvigorated their commitment to growing a strong safety culture. Facilities have reinstituted idle patient safety committees, engaged leadership and enhanced communication among departments.
Tiffany Richardson, Director of Quality Initiatives & Clinical Informatics at Ouachita County Medical Center (OCMC), said the hospital has seen a significant increase in near miss reporting after deciding to pilot Good Catch in its nursing and pharmacy departments. One process improvement, recommended by the pharmacy director, involved a change in the hospital’s Coumadin protocol and has made a huge impact.
“Implementation of a ‘Hard Stop’ policy, which requires drawing a baseline INR on all patients prior to receiving Coumadin, brought our instances of hypercoagulation down to ZERO over the last three months,” Richardson said.
Now that processes are in place for appropriate reporting, measuring and tracking, OCMC is set to go hospital-wide with Good Catch in October.
“We believe the impact will prove immeasurable for our patients’ safety,” Richardson said.
Lawrence Memorial Hospital (LMH) has seen an increase in reports at shift change and a heightened sense of urgency in fixing a problem when a safety concern is shared. One of the more challenging issues addressed at LMH involves how changes are made to “Do Not Resuscitate” orders when patients are discharged to the nursing home.
“Near miss data helped us see that our process wasn’t working,” Lory Williams, Med/Surg Director, said. “We needed to find a better way to pull nursing home leadership into the communication process with the patient, family and hospital staff, and now, that’s exactly what we’re doing.”
While ADNPSO established a Good Catch Awards program to reward extraordinary achievement in using near miss data to drive change, hospitals are using various in-house strategies to encourage staff and sustain campaign momentum. For instance, when staff report near misses at LMH, their names are entered into a pool. At the end of each six-month period, the hospital staff draw names from the pool and award three $50 prizes.
“Simple rewards, like candy bars, can be ample incentive,” Williams said. “It’s really about listening to the staff. ‘Small but enjoyable’ seems to work well for us.”
LMH even had an EMT report a near miss. Staff told him about the Good Catch campaign and showed him how to fill out a report. He earned a candy bar, and word of the Good Catch concept was carried beyond the hospital setting.
The above article is from AHA, a custom publication of Vowell, Inc., which also produces Arkansas Money & Politics.