A coffee spill on the floor.
A pair of no-skid socks left behind in a patient’s room as he or she takes a walk around the unit.
A set of EKG strips with a patient’s private information lying on a worktable.
A prescription left out of a patient’s large pharmacy order.
A busy nurse preparing a chemotherapy combination distracted by a nearby conversation.
A label on a drug vial inconsistent with the outside packaging.
Imagine these scenarios and more than 24,500 others like them playing out at MD Anderson this past year.
Fortunately, none of these situations resulted in a fall, medical mistake, patient privacy issue or threat to safety, but any of them easily could have.
Instead, these events were reported to MD Anderson’s Good Catch Program. It welcomes, encourages and rewards such filings by staff throughout the institution, and makes changes based on the information.
Accentuate the positive
MD Anderson started the Good Catch Program in 2003 as part of The University of Texas System’s “close call” reporting initiative for its six health care institutions.
It has evolved into a non-punitive change agent for new processes, improved clinical practice standards and renewed the culture of proactive patient safety awareness.
In the first 2 1/2 years of the program, only 174 events were filed anonymously. Today, between 1,500 and 3,000 reports per month are openly filed and available online.
What turned around the program and made it a source for productive change were simple approaches:
- adopt new and more positive terminology,
- redirect the program tone away from fear and punishment to openness, encouragement and reward and
- report back to the clinical community the steps taken to correct the potential error or risk.
Vigilant daily care
Bob Massey, Ph.D., a registered nurse, assistant professor and director of clinical nursing at
MD Anderson, says the Good Catch Program has roots in the chemical industry that rigorously analyzes near misses and implements detailed processes to prevent accidents.
“It’s the same concept with the Good Catch Program. We catch potential or actual errors, analyze what happened and then correct the action, process or system — all before it affects the patient.”
For the nurses on one inpatient unit, keeping a close eye out for potential or actual errors is part of their vigilant daily care of patients who have had complicated chest and lung surgeries.
Each nurse has a goal to report at least three close calls per shift, and their observations have generated new ideas for safer practices.
For example, Janet Taubert, advanced practice nurse, recommended putting down a spongy red mat designated a “no interruption zone” in her unit’s medication preparation area.
Good Catch reports showed that nurses often were interrupted or distracted in the prep area, leading to potential errors. To keep each nurse focused on the job at hand, colleagues may not talk to the nurse working on the red mat unless there is a critical patient care question.
Clinical Nurse George Prado found a simple and inexpensive way to decrease patients’ risk of falls.
Many post-surgery patients have multiple chest tubes and IVs. Yet, as part of their recovery, it’s important for them to walk and sit up. With a single Velcro strap, now known as George’s Velcro, the floor nurses bundle the tubing so a patient can move around much more safely.
Other inpatient floors have adopted the simple solution.
Prado’s simple find in a hardware store and the Good Catch Program were both highlighted in MD Anderson’s Magnet application, calling out the two as examples of new nursing knowledge, innovations and improvements.
“Just like the skin is the first line of defense against infection, so is Good Catch our opportunity to protect patients from something that’s potentially harmful to them.”