Rationale / Objectives
The Canadian Adverse Events Study determined in 2004 that the incidence of adverse events in Canada was 7.5%. In medicine, a 'near miss' or 'good catch' is an event that may have resulted in harm but did not reach the patient due to timely intervention or good fortune. Near misses may occur many times before an actual harmful incident. Many avoidable deaths have a history of related near misses preceding them. In March 2005, a “Good Catch” program was implemented in Edmonton’s Capital Health Region, as part of the region’s patient safety system of reporting, analyzing and managing incidents, adverse events and near misses.
Project/Program Description & Major Achievements
Prior to the implementation of the “Good Catch” program, Capital Health used a paper-based incident reporting system which included the ability to report Good Catches. The region recognized that by putting an emphasis on the reporting of good catches, the quality culture of Capital Health could be strengthened through recognizing contributions of staff and physicians. "Good Catch" was created to increase reporting of near misses, while enhancing the culture of safety to provide an opportunity to identify and implement risk reduction strategies. The program attempts to build an environment that fosters reporting to identify breakdowns in the system before they occur. During the first month of the program, 13 reports were received, but there has been an increase from October 2005 to February 2006 with the number of reports ranging from 103 to 135 per month.
To ensure that Captial Health maintained a balance between the components of the program (such as accountability, system transparency, and protection for the staff reporting incidents) legal counsel reviewed the program and provided guidance. The Quality Assurance Committee (QAC) was designated as the group responsible for all "Good Catch" related activities on site and at a regional level. Additionally, the "Good Catch" submissions are not associated with any details of the actual event or the improvement to protect the privacy of reporting staff and physicians. The team found that this element of the program design was important to staff and physicians, as it ensured protection under Section 9 of the Alberta Evidence Act.
People / Organizations Involved
Alberta Health Services-Edmonton Zone (previously Edmonton's Capital Health Region)
A multidisciplinary team developed the "Good Catch" program, along with a Project Management Plan to guide development and implementation. A Toolkit was also developed for the execution phase of the program. The Toolkit included posters, forms, information mailers and paycheque stuffers and was also replicated for the Regional Quality intranet site. The team also made presentations to all key management staff across the entire region on the Toolkit and answered questions over a three-month period prior to the program kickoff. The "Good Catch" program was also highlighted in all newsletters circulated in the region, both at the development site and at regional levels.All "Good Catch" submissions are received by the Good Catch Quality Assurance Committee (QAC). This group evaluates each submission against defined criteria. These criteria include: impact on patient safety, quality of patient care, service and potential for regional impact. In addition, at least two to four staff (including physician partners) are selected for recognition each month, and each staff member submitting a "Good Catch" gets a letter of thanks from the QAC. Every "Good Catch" is analyzed to determine what happened, why it occurred and what potential processes might be implemented to prevent an actual incident.
During the first month of the program, 13 reports were received, but there has been an increase from October 2005 to February 2006 with the number of reports ranging from 103 to 135 per month. The majority of reports received are related to medication administration, and this correlates with the actual incident reporting data in the region over the past few years. Consequently, medication safety has been identified as one of the primary focus areas for the Quality Improvement Program. From March 2005 to February 2006, 77 Good Catches have been selected for special recognition. An example of a "Good Catch" with significant benefits is that two multi-dose vials with different medications had very similar packaging; the manufacturer then changed the packaging.
|"Good Catches" by Month (March 2005-February 2006)||#|