According to the World Health Organization, a near miss event is “an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted.”
Examples of good catches in healthcare settings might include:
Each of the above may be the result of a larger systemic issue. Once you identify and address the root cause, you can revise and remediate your processes and procedures. Eliminating mistakes can be as simple as providing more robust staff training in a given area, such as medication administration.
In essence, each good catch provides a learning opportunity. When a team member catches and reports a near miss event, the safety team can dissect what happened and why. From there, they can attend to preventing similar incidents in the future. Having such procedures in place can help teams adapt to challenges and changing technology in the dynamic hospital setting.
A good catch program is crucial for maintaining robust, effective safety protocols.
Literature suggests that near misses occur anywhere between 3 and 300 times before an incident occurs.
Implementing a good catch safety program will provide your team with the meaningful data necessary to reveal process and system vulnerabilities. This allows them to develop and implement timely, proactive, data-driven improvement activities.
Furthermore, an incentive-driven good catch program can transform the hospital’s culture and attitude surrounding near miss events. Even the language surrounding “good catch” is a positive shift that can transform a practitioner’s mindset. When administrators reward a good catch with a desirable incentive, it helps shift the cultural attitude toward event reporting.
When staff feel empowered and responsible for patient safety, they are more likely to be vigilant and attentive to potential issues. As a result, you’ll improve both workplace satisfaction for staff and long-term safety outcomes for your patients.
For detailed strategies on improving patient safety through event reporting, check out the patient safety event reporting guide, which offers insights into simplifying and optimizing your reporting processes.
A meaningful reward can be as simple as a certificate, newsletter spotlight, or personal thank-you note. The CEO of one organization participating in ADN PSO’s campaign announced in a facility-wide email that, for each quarter, the staff member reporting the best good catch would receive a paid day off!
American Data Network PSO is proud of the achievements made by the 45 hospitals participating in our Good Catch Campaign initiative. The pioneering organizations who participated in this study increased Near Miss reporting by 47% over baseline. This data provided concrete evidence of the learning that happens when Near Miss events are shared and studied.
ADNPSO recently checked in with the Good Catch hospitals to find out how their Near Miss programs are faring post-campaign. Forty-two percent of the hospitals responded, and here’s what we learned from them:
For more details on the success of these programs, read about the Good Catch Campaign’s compelling results after 6 months.
Take a look at your organization’s patient safety event data over a 12-month period. What overall volumes, trends, and patterns do you see?
Closely examine the near misses reported. Who reported them? What kinds of events were reported most often — medication, communication? Note any trends revealed.
Isolating near miss data by month will be helpful in setting a stretch-goal for increasing near miss reporting over time. When setting your goal, keep in mind that experts estimate that every clinical staff member is aware of or involved in no less than 3 near misses per year.
Near miss reporting needs to be quick, easy, and accessible for frontline staff. Does your existing collection method (paper or electronic) facilitate ease? If not, consider introducing a simpler form.
Make sure staff understand the significance of their role in the reporting process. Everyone needs a clear and identical definition for near miss. They should also possess an understanding of plans for delivering and utilizing feedback. For guidance on capturing near miss data, refer to the patient safety event reporting guide to streamline reporting and boost staff participation.
To strengthen safety culture, you need to get a read on staff perceptions of the organization’s existing environment. AHRQ’s Hospital Survey on Patient Safety Culture can be integral to creating a profile for your organization’s approach to patient safety. To learn more about effectively utilizing this survey, check out A Comprehensive Guide to the Hospital Survey on Patient Safety Culture for in-depth insights and strategies.
Do you learn from your mistakes? Are staff comfortable reporting events when they happen? What do you do with feedback when you get it?
Additionally, you may be able to gauge perceptions of strengths and barriers that impact reporting efforts. Many teams accomplish this through leadership rounds, huddles, and even interviews.
Endorsement from the C-suite is essential to bringing physicians, managers, and frontline staff on board. It is also a sound strategy for securing resources for improvement efforts.
When talking to senior leaders, it’s important to present baseline event reporting data. Such data can help them understand how increased near miss reporting can translate into fewer adverse events. They need to be familiar with campaign goals.
Senior leaders need to know who is going to be responsible for managing the campaign. They should also be aware of what resources they are going to need to implement the program.
Examine your facility’s committee structure to either designate an existing team or form a new oversight team to manage the program. First, select a skilled facilitator to steer the team’s work. Next, identify additional staff who, serving as change agents, can drive efforts to increase near miss reporting facility-wide. This group needs to be a multidisciplinary assembly of strong, well-respected staff leaders committed to leading by example.
Use findings revealed through reviews of the organization’s baseline data, Hospital Survey on Patient Safety Culture, and other assessments. These tools can help develop strategies that address weaknesses and leverage strengths.
What issues need to be considered in introducing a near miss campaign in your facility? Will staff be receptive, or will they shy away? Are there clear problem areas that you need to prioritize?
The oversight team will need to establish a reporting process. They can also establish a process that ensures a monthly review of near miss details. Furthermore, they should complete an evaluation of goal progression. Continuous review of qualitative and quantitative data will help identify opportunities to redesign systems and processes.
Design an internal reward and recognition program. It should offer opportunities to fuel learning through shared success stories, celebrate achievements, and involve leadership.
Thorough staff education and consistent communication are essential to campaign success. Expose all frontline staff and physicians to near miss education. Groom leaders, managers, and supervisors to serve as educators and encouragers within their areas. Again, everyone needs to know how to identify a near miss and how to report one when discovered.
Generating awareness and inspiring ongoing staff engagement will require the use of multiple channels of communication. These can range from newsletters and email alerts to safety huddles and leadership rounds.
Work toward building a toolkit of educational resources and promotional materials that can be used to train staff and bolster engagement over the course of the campaign, or use ADN’s free toolkit for Good Catch campaigns to get started.
Consider utilizing existing resources. You can also create some of your own tools like:
A monthly review of near miss reports conducted by the oversight team will help identify any areas where near miss reporting may be stalled or declining. This will prompt the modification of strategies and interventions.
Timely, relevant feedback is critical to keeping staff engaged at all organizational levels, as is the continuous implementation of the campaign rewards program. Take every opportunity to recognize patient safety champions. Celebrate the individuals, departments, and teams who are using near miss analytics to take action that ultimately reduces risk and prevents patient harm.
Incorporating elements from the national patient safety goals guide can further strengthen your safety strategies.
HRO Trait: Sensitivity to Operations – The Key Concepts and Benefits