Document Type
Poster
Original Publication Date
2024
Date of Submission
October 2024
Abstract
Purpose: High reliability principles and patient safety tenets emphasize the importance of preventative measures and mitigation in near-miss safety events to prevent patient harm. Near-Miss Event (NME) reporting at VCU Health was recognized as waning in the face of higher-level harm events. Misnomers in the environment led front line team members to believe that their Good Catches, acts of preventing harm from reaching the patient, did not warrant safety event reporting as they were “just doing their job.”
Action: Fishing for a "Good Catch” was developed to encourage team members to recognize, speak up, and aid in the prevention of patient harm by reporting potential safety events and informing the organization of improvement opportunities. The Good Catch Program (GCP) was launched during National Patient Safety Awareness Week 2023 to optimize dissemination and continues to gain recognition through monthly Good Catch of the Month callouts. Leveraging the patient safety event reporting platform, interactive questions are used to identify events that "did not reach the individual" and probe the question to the reporter: "Was this a Good Catch?". The catch of the month is randomly drawn from a monthly report. Winners are recognized on the intranet, during team huddles, and their stories are highlighted as safety moments in system-wide meetings.
Results: In the first eight months of CY24, the GCP averaged 35 submissions/month compared to 11 submissions/month in the last eight months of CY23. Since inception, there has been a steady increase in monthly NME reports as well as Good Catch submissions, demonstrating integration into practice and allowing leaders to take proactive action to address system weaknesses.
Lessons Learned: Positive reinforcement of safety culture behaviors through team member recognition has a positive impact on NME reporting which is imperative in collaborative efforts to mitigate risks and prevent future patient harm.
Rights
This poster is distributed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License (https://creativecommons.org/licenses/by-nc-nd/4.0/).
Is Part Of
VCU Health Nursing
Comments
Poster Presented at:
Institute for Healthcare Improvement (IHI) Forum, Orlando, Florida, Dec. 2024
Virginia Hospital & Healthcare Association (VHHA) Patient Safety Summit, Feb. 2025