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Archived Service Delivery Profile:

Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety


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Snapshot

Summary

The University of Texas M.D. Anderson Cancer Center implemented a multifaceted initiative, known as the Good Catch Program, to increase the reporting of events that could potentially harm patients, visitors, and staff (these events are often referred to as "near misses" or "close calls”). Nurses and other frontline providers are positioned to proactively identify, interrupt, and correct these events. Key elements include a change in terminology from negative to positive terms and phrases (e.g., from "close call" or "near miss" to "good catch"); friendly, team-based competition to promote reporting; an end-of-shift safety report; executive leadership–sponsored rounds and incentives; and a multidisciplinary workgroup to promote reporting. The program led to a dramatic initial increase in reporting of near misses and close calls, spurred development of action plans designed to address the common causes of potential errors, and contributed to numerous system changes. As these changes have occurred, the number of events that could potentially cause harm—and hence the number of reports—has declined, but reports still remain well above baseline levels.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of the number of reports submitted about potential errors.
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Developing Organizations

Department of Nursing Administration, University of Texas M.D. Anderson Cancer Center, Houston, Texas; Department of Nursing Research and Evidence-Based Practice, University of Texas M.D. Anderson Cancer Center, Houston, Texas; University of Texas Health Science Center School of Nursing, Houston, Texas
University of Texas M.D. Anderson Cancer Centerend do

Date First Implemented

2005

Problem Addressed

Many actual and potential medical errors occur in hospitals on a daily basis, and these events represent significant opportunities to catch, learn from, and correct mistakes before they harm patients. Yet, these occurrences often go unreported, thus negating the opportunity for learning and improvement.
  • Many errors and deaths from errors: The Institute of Medicine's 1999 report, To Err is Human, documented the tremendous number of errors made in hospitals, and estimated that 44,000 to 98,000 individuals die each year from these errors.1
  • Inadequate reporting: In 2003, M.D. Anderson implemented the Close Call Reporting System to encourage anonymous reporting of close calls, near misses, and potential errors; to identify possible causes of the errors; and to develop creative solutions. Yet, only 175 reports were submitted in the first 2.5 years of the program, leading to a reconsideration of how to encourage reporting.1 Several factors appear to have contributed to the relative lack of reporting:
    • Reporting of only errors considered to be life threatening
    • Fear of reprimand for making a mistake
    • Disagreement over whether an error occurred
    • Anticipated negative responses to errors by hospital leadership
    • The significant time and effort required to report an error

What They Did

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Description of the Innovative Activity

The Good Catch Program combines five main components: a change in terminology from negative to positive terms and phrases; friendly, team-based competition to promote reporting of "good catches"; an end-of-shift safety report that allows for identification and discussion of concerns related to patient safety that occurred during the shift; executive leadership–sponsored rounds and incentives to acknowledge individual contributions; and a multidisciplinary workgroup to promote the program. Each of these are described in more detail below:
  • Changing of terminology: The old Close Call Reporting System used phrases such as "near misses" and "close calls" to describe potential errors, which emphasized the negative potential consequences of an error. The new system changes the terminology to focus on the positive; for example, the term "good catch" is used to emphasize the potential benefits of reporting and preventing potential errors.
  • Team-based, friendly competition: Using a baseball theme, five inpatient units form teams to participate in friendly competition to see which team can voluntarily report the most "good catches." One point is awarded for each report and executive leadership recognizes the team with the greatest number of reports over a designated period. Unlike the old system (which accepted both paper and online reports), all reports under the new system are submitted using a team-specific entry code through an online system that automatically assigns points to the submitting team. (The program originally allowed individuals to submit reports anonymously, with only the team being identified; information provided in June 2011 indicates that reporting is now done using open identification of the individual, a change requested by staff to allow issues to be addressed more effectively and changes made more easily.) The program has been rolled out to all inpatient nursing units through the formation of an "inpatient league" comprising "divisions"; teams compete to improve the patient safety culture, with a divisional playoff and "World Series" being played. All units that contribute to an increase in reporting are recognized through this system.
  • End-of-shift safety report: At the end of each shift, team members are asked to recall interventions during the shift that encouraged patient safety and reminded to report any "good catches." Each team uses a log to ensure participation in these end-of-shift reports, which encourage a real-time discussion of potential errors and possible solutions at the team level.
  • Leadership rounds and incentives to acknowledge top performers: The chief nursing officer makes rounds on the participating units to hand out "Good Catch" pins to participating team members. During these rounds, the chief nursing officer engages in a discussion with the teams about patient safety and the types of actual and potential errors identified. The chief nursing officer also acknowledges employee interventions or suggestions to prevent errors and promote patient safety. Each month, executives recognize patient safety champions, designating them "most valuable players."
  • Multidisciplinary workgroup: Two team members from each unit, along with representatives from the Quality Improvement Department, managers of the former Close Call Reporting System program, and unit associate directors, serve as part of a "Good Catch" workgroup. Each workgroup member serves as a program champion, facilitating communication with their teams and promoting friendly competition to increase reporting. To support its work, the group receives periodic updates on the progress of each team.
  • Expansion to diagnostic imaging: The Good Catch program has expanded to the diagnostic imaging service, with the goal of preventing delays in diagnostic imaging as a result of patients not having the required prestudy laboratory tests or chest x-rays. When a patient is being prepared or arrives for a study (e.g., a computed tomography with contrast) and has not had the necessary prestudy laboratory tests or chest x-ray, a Good Catch report is entered into the system. Diagnostic imaging staff evaluate the data to determine trends and identify system or process issues causing repeated failure to have appropriate prestudy requirements completed.
  • Data collection improvements: Over time, several improvements have been made to data collection.
    • Improved forms: The electronic submission forms used to report good catches have been revamped to improve the flow from one section to another, resulting in easier, more rapid entry.
    • Taxonomy: A taxonomy has been implemented to identify the level of harm the event may or may not have posed. The taxonomy has allowed inclusion of the Good Catch reports into the institution's incident reporting system, increasing reports of potential harm. This step has allowed the institution to meet Joint Commission standards for reporting and creates a more robust system for evaluating latent events that might contribute to errors.
    • Information consistency: The institution has blended information obtained from Good Catch reports with that found in Incident Reports to obtain consistent information entry for each system. For example, more than 60 percent of Good Catch reports and a significant number of electronic Incident Reports involve medication transcription issues, but a review of the information entered in Good Catch and Incident Report systems involving medication transcription errors did not match. Blending the information entry requirements for the two systems allows for more reliable and valid information, leading to easier identification of latent events and trends that can prompt process or system changes.

Context of the Innovation

M.D. Anderson Cancer Center, founded 70 years ago as part of The University of Texas System, is one of the three original Comprehensive Cancer Centers designated by the National Cancer Act of 1971 and one of 40 designated centers today. With faculty and staff working in more than 50 buildings in Houston and Central Texas, M.D. Anderson is one of the largest cancer centers in the world. The physical plant includes an inpatient pavilion with 546 beds, five research buildings, three outpatient clinic buildings, a faculty office building, a proton radiation clinic building, and a patient-family hotel. As noted earlier, the Good Catch Program was developed as an enhancement to an earlier program that did not meet expectations in terms of increasing the reporting of potential errors. The revised program was specifically designed to address a number of factors that contributed to the lack of reporting under the old system.

Did It Work?

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Results

A 6-month pilot test found that the program led to a dramatic initial increase in the reporting of potential errors. These reports allowed teams to identify common problems that lead to potential errors and to create action plans to address these common safety concerns. These improvements have led to a decline in potentially dangerous events and hence a subsequent dropoff in reporting, although the number of reports remains well above baseline levels.
  • Significant, dramatic initial increase in reporting: During the 6-month pilot, staff submitted 2,744 reports of potential errors, a 1,468-percent increase over the 175 reports submitted during the first 2.5 years of the Close Call Reporting System.1 Information provided in June 2011, indicates that over 125,000 reports had been entered into the electronic reporting system.
  • Action plans to address safety concerns: The increase in reporting has proven to be a springboard for the development of action plans to address common sources of errors, including medication dispensing and labeling, transcription, communication, equipment, policy issues, clinical procedure issues, and prevention of falls.
  • Process and system improvements: The program has prompted the identification of system or process breakdowns and subsequent improvements to address them. Examples include the following:
    • Decentralized distribution of infusion devices: To improve efficiency and user access, the institution changed from a centralized distribution of infusion devices to a decentralized unit-based system. Nurses had been waiting more than an hour to receive an infusion device, thereby causing a delay in therapy. The new process allows the nurses to immediately obtain the device and begin infusion therapy immediately. (The devices continue to be returned to the pharmacy department for cleaning and maintenance.)
    • Program to reduce transcription errors: Analysis of Good Catch reports indicated that a large number of transcription errors were due to ineffective communication between the pharmacists and unit nurses. Nurses and pharmacists met to develop a plan to improve communication. As a result, a pilot program is being implemented where nursing and pharmacy staff meet monthly to collaborate and solve system and process issues that could cause transcription errors. Good Catch data will be reviewed by the group and used to identify opportunities for improvement.
    • Multiple programs that lead to fewer falls: More than 1,000 Good Catch reports involved actions by staff to prevent slips, trips, or falls; the institution's new policy and process related to falls, along with other related activities, has led to a decline in falls and injuries from falls.
  • Subsequent decline in reports (but still well above baseline): Due to the system and process changes made as a result of the Good Catch reports (described above), the number of potential errors has declined, and hence the number of reports has dropped off as well, from an average of 2,000 to 3,000 per month shortly after implementation to between 1,000 and 2,000 a month at present (a figure still well above baseline).
  • Greater diagnostic imaging throughout: The diagnostic imaging department used Good Catch reports to identify where processes break down, thus enabling it to reach its goal of 200 completed computed tomography scans per day, well above the 100 to 150 daily scans completed before program implementation.
  • Improvement in patient safety culture: A 2008 research study that administered pre- and post-implementation surveys to more than 600 nurses found that the Good Catch Program enhanced their willingness to report potential and actual errors, suggesting that the culture of the organization has changed, with a greater emphasis on patient safety.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of the number of reports submitted about potential errors.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Implementation of initial program: In 2003, M.D. Anderson implemented the Close Call Reporting System to allow employees to provide anonymous error reporting and to promote patient safety and error reporting as an institutional priority. Educational sessions made employees aware of the option for anonymous error reporting and explained how to use the system. Leaders emphasized to staff their belief that it is human nature to make mistakes and to correct and learn from errors. To that end, employees were encouraged to report near misses, potential errors, and close calls; to identify possible causes of the error; and to develop creative solutions. As noted, the lack of reporting in the first 2.5 years after program launch created the need for a revamped approach.
  • Pilot testing: In December 2005, the revamped program was implemented on five units and tested for a period of 6 months. At first, nurses remained reluctant to report potential errors, but the hesitation dissipated as they saw the positive response from executive leadership and the actions taken to address system issues.

Resources Used and Skills Needed

  • Staffing: The program relies on existing staff who participate as part of their regular duties.
  • Costs: The program required minimal financial resources to cover supplies and other incidental expenses.
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Funding Sources

University of Texas M.D. Anderson Cancer Center, Houston, Texas
The program was funded internally by M.D. Anderson Cancer Center.end fs

Tools and Other Resources

Agency for Healthcare Research and Quality. Patient Safety Culture Surveys page. Hospital Patient Safety Culture Survey. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/

Coyle GA. Designing and implementing a close call reporting system. Nurs Adm Q. 2005;29(1):57-62. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Consider use of electronic systems: While paper-based systems can be used, electronic reporting has many advantages.
  • Engage leaders: Senior leaders can play an important role in educating staff on the importance of error reporting and in creating a nonpunitive environment.
  • Be patient and have realistic expectations: It takes time for nurses and other staff to trust and believe in the value of the system.

Sustaining This Innovation

  • Provide regular updates: Provide the workgroup and staff with weekly electronic updates on the program, including any changes made based on the results of Good Catch reports. These progress reports can keep staff and leaders vested and interested in sustaining the program.
  • Continually emphasize importance of reporting: Have leaders engage in regular conversations with staff about the importance of error reporting.
  • Expect declines in reports: The number of reports should decline over time as the use of action plans and other interventions address common root causes of potential errors, thus reducing the number of near misses and close calls.

More Information

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References/Related Articles

Mick JM, Wood GL, Massey RL. The good catch pilot program: increasing potential error reporting. J Nurs Admin. 2007;37(11):499-503. [PubMed]

Footnotes

1 Mick JM, Wood GL, Massey RL. The good catch pilot program: increasing potential error reporting. J Nurs Admin. 2007;37(11):499-503. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 24, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 23, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.