GREAT CATCH PROGRAM: PROMOTING REPORTS OF NEAR-MISS CLINICAL EVENTS

By Marvin Dewar

A challenge in promoting safety is getting a true report of the number of potential quality and safety events (“near-miss” events) that occur in clinical practice, and an adequate description of them. Near-miss clinical events occur in much greater number than actual patient harms, and increasing the number of near misses reported in a quality and safety program can paradoxically decrease the number of patient harm events.

Evaluating a near miss provides an opportunity to analyze failures in established processes and systems and to make changes before patients or others are impacted. However, safety events and near misses are widely underreported by sta for a number of reasons, such as potential embarrassment to themselves or others, or concern about repercussions.

The University of Florida Physicians team strives to create a culture in which people are comfortable reporting safety events and near misses.

UFP has established incentives for individuals who contribute to the improvement of the organization by communicating near-miss events. Just as the Customer Service is the Key (CSK) program is intended to promote a culture of service excellence, UFP developed a recognition award that promotes a culture of quality and safety excellence.

The Great Catch Program was implemented during the summer of 2009. Any provider or staffmember reporting a “near-miss” event receives a personal note and a “You Make The Difference” pin from the practice CEO, thanking them for their contribution and emphasizing the significance of their role in improving patient and workplace safety. One contributor each quarter is selected to receive the Great Catch Award: a $75 gift card and an announcement describing their contribution.

Following initiation of the Great Catch program, data show an increase year-to-date in patient safety event reporting of 41 percent over the previous year. Over the same timeframe, reports of near-miss events increased 100 percent! As a result of the program, we’ve made changes to improve medication storage (with frequently used medications moved to secure storage areas directly in procedure rooms); fostered collaboration with Florida SHOTS and Epic to develop an interface so that previous immunization information is available within Epic; and developed Well Child order sets to assist pediatricians and family physicians with ordering age-appropriate vaccines, labs and medications.

UFP will continue to enhance the Great Catch Program to recognize and reward the practice reporting the highest number of near miss. As programs like Great Catch help promote a culture change of safety and transparency, allowing potentially harmful errors to be prevented before they happen, we all should anticipate a safer and more e ective place to work and to receive care.

— DR. DEWAR IS SENIOR ASSOCIATE DEAN, CHIEF EXECUTIVE OFFICER AND CHIEF MEDICAL OFFICER, UNIVERSITY OF FLORIDA PHYSICIANS