A system developed at Johns Hopkins Medicine in Baltimore, Maryland intends to prevent accidents before they happen by encouraging clinicians to report situations that might lead to dangerous or even life-threatening incidents for patients. Known as the “Good Catch Awards,” the program distributed 27 honors in its first two years for reports that led to positive changes in patient safety. Such changes ranged from modifications in pharmacy order sheets to a national recall of improperly-labeled drugs.
The “Good Catch” program operates on the theory that, instead of errors being attributable to one individual, most errors result from a flawed system in a hospital. It stresses to doctors and other medical practitioners that its purpose is to find solutions to common errors, not to assign blame for those errors. Not all doctors and others have embraced the system yet, but most acknowledge that it is a vast improvement over safety systems at most hospitals. Robert Stoelting, MD, president of the Anesthesia Patient Safety Foundation, compared the system to those used in nuclear plants and airlines, where the responsibility for safety is shared by everyone. He suggests the creation of a national database to collect hospitals’ self-reports of “errors and so-called near misses” in order to better share safety information and create greater opportunities to improve patient safety.
Other hospitals have implemented their own “Good Catch” programs, inviting clinicians to share examples of near misses that could have resulted in patient injury but did not. The University of Connecticut Health Center offers a “Good Catch” award for near misses that lead to improvements in patient care. The Minnesota Hospital Association awards a “Good Catch for Patient Safety Award” to clinicians “who demonstrate their commitment to keeping patients safe by ‘speaking up’ to prevent potential harm to a patient.” The Brantford Community Healthcare System in Brantford, Ontario, Canada solicits stories from its medical staff about incidents that contribute to its “culture of safety.”
These systems demonstrate an admirable commitment to improving patient safety by identifying problem areas and searching for collaborative solutions. By not assigning blame to a single individual or department, “Good Catch” programs can encourage hospital staff to freely report and discuss incidents that could affect patient safety. A hospital consists of a complicated web of professionals, from the doctors who oversee the care of all patients, to the nurses who care for the patients, the pharmacists who dispense the medications, and the staff who keep the facilities and equipment clean. All of these individuals play an important role in a hospital’s operation, and a breakdown in one part can affect all the others. The impact of any breakdown on patient safety is difficult to predict. Hopefully these programs will expand to more hospitals and promote a wider “culture of safety,” which can only work to patients’ benefit.
The Maryland pharmacy error attorneys at Lebowitz & Mzhen are skilled at reviewing injuries due to medication errors and assessing liability and damages for those injuries. Contact a lawyer today for a free consultation to review your case.
Patient Safety Network, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
Good Catch program encourages near-miss reporting, Strategies for Nurse Managers, Inc.
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The Benefits and Problems of Electronic Medical Records Systems, Pharmacy Error Injury Lawyer Blog, August 10, 2011
Report Warns Consumers to Take Precautions With Drug Labels and Instructions, Pharmacy Error Injury Lawyer Blog, July 25, 2011
Children’s Hospitals Form Collective Effort on Patient Safety to Prevent Medication Errors, Pharmacy Error Injury Lawyer Blog, April 13, 2011