A program that encourages clinicians to report risky incidents before an adverse event happens has led to 27 potentially life-saving changes at John Hopkins in only 24 months, according to an article in this month's issue of Anesthesiology News.
The "Good Catch Award" program acknowledges that it's usually a system and not an individual that is responsible for errors. The program aims to expose--and subsequently fix--problems within the system.
According to Anesthesiology News, most of the incidents reported were near misses--unsafe conditions that could have harmed patients but hadn't yet. Only 5 percent to 10 percent of the incidents "caught" had harmed patients.
Yet these near misses often go unreported because even though they put patients at risk, the risk is less evident, noted Dr. Justin Hamrick, a third-year anesthesia resident at Hopkins, in the article.
To highlight that reporting such instances will protect clinicians, Johns Hopkins publicly rewards individuals, rather than place blame, for catching errors before they happen.
For example, after reporting that a patient almost received incorrect medication, a clinician won a Good Catch award with a description of the "good catch" posted on wall boards within Hopkins' surgical suite, notes the article. What's more, the reporting of this potential error led to a national recall of improperly labeled drugs.
The next step to better transparency and enhanced patient safety is to aggregate all of the reported errors and near misses into a national database so that hospitals can learn from one another and more efficiently prevent their reoccurrence, Anesthesia Patient Safety Foundation President Dr. Robert Stoelting told Anesthesiology News.
However, greater transparency does have its shortcomings. As hospitals in Maryland learned firsthand, better reporting oftentimes can reveal more adverse events.
- read the article
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