Report near misses to improve hospital safety

pills medicine pharmacy
Potential mistakes can be as important a learning tool as mistakes with major consequences. (stevepb/pixabay)

Mistakes that get corrected before they cause harm to patients offer significant value as learning opportunities for hospitals—but only if they get reported.

Small slip-ups can have grave consequences in a hospital setting, but hospital culture has long tended toward secrecy on information about medical errors. The University of Texas MD Anderson Cancer Center—which found hospital employees were reticent to report potential mistakes—created the Good Catch Program, which emphasizes positive framing and friendly competition, as well as end-of-shift reports designed to help identify and discuss potential errors.

The success of a six-month pilot test that significantly increased reporting of “good catches” has gained traction in other institutions, such as Signature Healthcare Brockton Hospital’s Great Catches program, part of a larger Community Hospital Acceleration, Revitalization, and Transformation (CHART) grant, described in a recent article from the Betsy Lehman Center for Patient Safety in Boston.

“The program is designed to help drive up the number of safety reports, so we can keep better track of our composite patient safety numbers,” said the hospital’s CHART program coordinator, Deborah Jean Parsons, Ph.D., giving the hospital an opportunity to improve its safety systems by responding to mistakes before they cause patient harm.

For example, the article described an elderly patient who transferred a new supply of blood pressure pills from a blister pack to an old pill bottle, without noticing that the new pills contained twice the dosage as the ones listed on the bottle’s label. A follow-up call from a pharmacist caught the potentially harmful situation.

Patient-centered interventions have helped to improve adherence and reduce unnecessary readmissions, but in this case, the pharmacist’s intervention could have been lifesaving. “Our CHART patients are not only safer because of the pharmacists’ attention to medications and potential errors, but they’re healthier too,” said Parsons. “It’s a win-win for everyone.”