A Near Miss or Good Catch is a patient safety event that did not reach the patient, while an incident is an event that reached the patient, regardless of harm. Experts view Good Catch events as some of the best predictors of medical errors. Yet, these events are notably underreported.
Research supports that Good Catch initiatives can significantly enhance safety culture. By focusing on identifying system fractures before patients are affected, healthcare teams can address issues early. Good Catch events are easier for staff to discuss than incidents since they carry fewer emotional barriers and less judgment. These near misses provide valuable lessons, revealing weaknesses and strengths. Teams learn where improvement is needed and how to go about it.
The American Data Network Patient Safety Organization (ADNPSO) recognized near misses as a trust-building opportunity among teams and a catalyst for reducing adverse events. Studies suggest that every preventable event is preceded by a series of near misses. Therefore, as reports of near misses increase through a Good Catch program, adverse events are expected to decrease.
In 2016, a review of ADN PSO data revealed that Near Misses represented only 6.8% of all reported events. With 81% of facilities surpassing their baseline, the potential for growth was evident. Launching a Good Catch program across 45 hospitals in Arkansas was challenging but yielded excellent results.
Forty-five hospitals, dispersed across the state of Arkansas, participated in ADNPSO’s Good Catch initiative.
“Hospitals achieved 95% of the campaign goal and saw a 47% increase in near miss reporting over baseline.”
Overall, these hospitals achieved 95% of the campaign goal and saw a 47% increase in near miss reporting over baseline. Together, participating facilities reported an average of 246 more near misses per MONTH during the 2017 campaign.
To learn more about setting up a successful program, consider reviewing this Good Catch program guide.
Interdisciplinary teams dissected near misses and swiftly addressed patient safety issues as identified. Bringing staff from multiple areas into the conversation meant more players had opportunity to offer expertise in developing strategies to reduce risk.
Not every hospital was already tracking near misses, but they embraced this Good Catch initiative opportunity to rethink their reporting needs, work toward electronic methods, and design forms to use in the interim. Some newly created paper forms invited staff input that was used to develop protocol changes resulting from their discoveries.
You can find more tools to optimize reporting strategies in this patient safety event reporting guide.
Frontline staff, physicians, and non-clinical staff spoke up with greater confidence and became more fully invested in safety goals. Through the Good Catch initiative, staff gained ownership in their role as patient safety advocates.
The Good Catch initiative enabled facilities to share lessons not just departmentally but across the entire organization. Employee trainings highlighted exceptional examples of error prevention and situational awareness, reinforcing the significance of national patient safety goals. For more details on aligning with these standards, explore this national patient safety goals guide.
Teams acted in a timely manner on issues revealed through near miss analysis.
Modifications in one facility looked like this:
Another facility reported similar success stories:
Participating facilities ranged from those tied to large, urban based systems to significantly smaller, rural hospitals. One Critical Access Hospital improved 126% over baseline and nominated a standout physician who was recognized with a quarterly Good Catch Award.
When you keep data associated with the Good Catch initiative in front of the C-suite, the numbers are hard to ignore. In turn, staff will respond when they see leadership embracing Just Culture and opportunities to expose vulnerabilities and make improvements.
Staff need reassurance that reporting a near miss does not mean someone is going to be in trouble. Some facilities discovered that near misses had been happening all along but staff were trying to fix the issues on their own without sharing lessons learned in order to prevent recurrence. Compliance happens as staff begin to understand that you can’t fix what you don’t know is broken.
While rewards and incentives provide encouragement, consistent communication is the greater motivator. Pulling staff into the conversation, listening to what they say, and acting on their expertise speaks volumes. Keeping progress reports in front of staff and spotlighting exactly how their work has impacted change is empowering.
While educating and encouraging staff may be intense at first, Champions step forward to assist in advancing the message that we can all be excellent patient safety advocates!
The Good Catch initiative across 45 hospitals in Arkansas successfully improved patient safety by increasing near miss reports by 47%. By revitalizing safety committees, reimagining reporting tools, and empowering staff, the initiative fostered a culture of transparency and proactive risk reduction. As hospitals continue to focus on Good Catch programs, the lessons learned will further reduce adverse events and strengthen patient safety across the board.
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