Staff members are often trained to report a potential medical error, or near-miss event. However, more often than not, these events go unreported.
In 2003, The University of Texas (UT) System, which is made up of six health institutions, developed a system that allowed the anonymous reporting of close calls, near misses, and potential errors.
Despite the reports' anonymity, only 175 were gathered during the first two-and-a-half years of the program.
After seeing this result, Robert L. Massey, PhD, RN, NEA-BC, director of clinical nursing at UT's M. D. Anderson Cancer Center, and a former colleague wanted to know why the program was not working and how they could encourage staff to report medical errors.
In 2005, Massey and his former colleague proposed and implemented a pilot test of the Good Catch program at M. D. Anderson. By putting a positive spin on the reports (increased reporting of near misses helps the hospital learn how to prevent future errors) and developing a competition to encourage reporting, M. D. Anderson received 2,744 reports of potential errors during the initial six months of the pilot program.
A positive twist on reporting medical errors
The Good Catch program's pilot test began in December 2005 and ran through May 2006. Three components make up the program and help it stand out from the previous program used by the organization:
- Terminology change
- End-of-shift safety reports
- Incentives, such as safety awards, which are supported by executive leadership
M. D. Anderson's original reporting system used the terms "near miss" or "close call" to report potential errors.
"The phrases 'near miss' and 'close call' came across to the staff as almost negative," says Massey.
After taking a close look at the terminology, M. D. Anderson chose to use the phrase "good catch" to identify when a potential error is reported.
"Using 'good catch' takes a more positive connotation, and staff members are not as discouraged to report potential errors," says Massey. "These types of events never get to the patient or else they would not be considered a good catch."
In addition to changing the terminology, M. D. Anderson decided to encourage staff members to report these potential errors at the end of their shifts through an end-of-shift safety report. The communication encourages staff coming off shift to talk with the staff coming on shift about any good catches that occurred throughout the shift. Doing so helps all staff members maintain awareness about potential errors.
For example, if a staff member on the morning shift reports a transcription order error, the next staff member coming on shift is made aware of the situation so he or she can be aware of a potential good catch of the same nature.
"If this happens multiple times on a shift or in a 24-hour period, we can address the situation immediately," says Massey.
World Series of error reporting
Friendly competition among staff is also used to encourage the submission of good catches at M. D. Anderson. The organization uses a baseball theme as a form of competition, says Massey. Inpatient units form teams—complete with mascots created by each team—and the team that reports the most good catches at the end of each "season" wins.
"We follow the same schedule as the regular baseball season," says Massey. "And around October, we hold a World Series for the two teams in each league that have the most good catches up to that point."
Throughout the year, teams receive safety awards for submitting the most good-catch reports. The teams are also part of divisions, each of which hosts its own divisional playoffs for the most good-catch reports.
Eventually, the teams with the most good-catch reports in each division are eligible for the World Series. Both teams then compete for the championship. Massey and his staff monitor any increase in reporting greater than 10% to make sure there is no padding of results.
At the conclusion of the World Series, the winning team receives a safety award party—usually a pizza/cake party. The team also gets a trophy.
To read more about the Good Catch program, see the May issue of Briefings on Patient Safety, a product of Patient Safety Monitor.
Sarah Kearns is an editor for HCPro in the Quality and Patient Safety Group. Contact Sarah at skearns@hcpro.com.