Have you ever encountered a situation that could cause harm to a patient or other staff member and came up with a good idea to remedy it (Good Recommendation)? Or have you ever realized something could have affected a patient or staff member but you caught it before anyone was harmed (Good Catch)? If so, you may be eligible for a Good Catch Program award.
To become eligible, simply submit a Patient Safety Net (PSN) event report describing what occurred and be sure to include your name. Your area/unit leadership will evaluate the report and indicate if it is a Good Catch/Good Recommendation.
The Healthcare Event Evaluation Team (HEET) will complete a final review of the event and determine if it is indeed a Good Catch/Good Recommendation. If accepted, the person who submitted the event will receive an acknowledgement letter and tote bag from UW Health's Patient Safety Officer. A recognition letter will also be sent to the employee's manager.
During Quality and Safety Week (October), all recipients will be entered into a drawing for a grand prize.
Examples of Good Catches/Recommendations
Good Catch: Medication ordered for wrong patient
Registered Nurse (RN) noted a new one time dose Vitamin K order on the patient's medication administration record (MAR). The RN was unclear as to why this medication was ordered for this patient and reviewed the chart but still was unclear. The RN discussed her concern with the providers and they were unsure as to why this medication was ordered as well. After further review, it was ordered on the wrong patient.
Good Catch: Risk of Confidentiality (Health Insurance Portability and Accountability Act - HIPPA) violation
Scheduled daily cleaning duties were being completed, upon emptying of the trash cans, confidential patient care information documents were found left in the trash cans and not in a confidential bin as required per policy to protect confidentiality and comply with HIPPA regulations. Upon leaving the cafeteria notecards were found on the ground. After a closer look it was noticed they contained a patient's confidential information. Instead of throwing them in the regular trash cans they were discarded in a confidential recycle bin. There was no indication of an actual breach of HIPAA or Wisconsin health care privacy laws, however failing to use confidential recycling bins does risk a breach of confidentiality.
Good Catch: Fluid Restriction
A food tray was delivered to patient's room. The Nursing Assistant (NA) went to set up tray and realized the patient (who was on strict fluid restriction) received 2 cartons of milk. NA looked at tray slip and saw there was not supposed to be the carton of milk on the tray only the 1/2 cup of milk. NA removed the additional milk and notified Nurse.
GOOD RECOMMENDATION: Prophylaxis for patients with moderate/severe reaction to iodinated contrast
Patient with a contrast dye reaction needed prophylaxis prior to a radiology procedure. The prescriber and reporter had to track down recommendations (about 30 minutes) to find them. The wrong medications were selected which delayed the patient receiving pre-medications and resulted in delay of the scan and subsequent discharge.
Recommendation: Develop a contrast reaction prophylaxis order set.
GOOD RECOMMENDATION: Distribution of After Visit Summary (AVS)
Physician completed appointment with patient, and prints the AVS at either the receptionist desk or their own pod, patient was given an AVS of another patient.
Recommendation: Have the receptionist print the AVS after making the follow up appointment and make this standard from clinic to clinic.