When it comes to predicting potential fouls, nurses at Houstons University of Texas M.D. Anderson Cancer Center are scoring home runs more than 23,000 since piloting the Good Catch Program in 2006. Its unknown how many might have progressed to actual errors, but its success captured the National Patient Safety Foundations second annual Stand Up for Patient Safety Management Award.
Good Catch promotes the centers Close Call Reporting System (CCRS), which had fielded only 175 reports since its season opened in August 2005. In a city thats home base for the Houston Astros, the MD Anderson didnt choose the name Good Catch on the fly.
It shifts from the negative implication of near miss or close call to focus positively on nurses actions to identify and prevent potential errors with medications, equipment and patient care. Actual errors are addressed via the Incident Reporting System.
We wanted to change the culture of error reporting and increase the number of reports by making it a fun, friendly competition, says JoAnn Mick, PhD, RN, MBA, associate director of nursing research, who proposed the program in late 2005. Now hospital-wide with four divisions, it was phased in over 18 months, five nursing units at a time, to provide sufficient coaching, mentoring and team development. Each unit chose a team name, and some created team logos.
Staff is often reluctant to report potential weakness because they think it reflects poorly on a unit, says Barbara Summers, PhD, MSN, vice president for nursing practice and chief nursing officer. Were trying to create a fair and just culture in which nursing staff feel empowered to identify opportunities to improve patient safety, and eliminate any fear of reporting, she says.
The staff has changed their way of thinking about near-events and systems. Documenting solidifies their commitment to patient safety. They dont participate because they can be anonymous or because they want individual credit they want their team to get credit for their performance, she says.
The teams of nurses compete by divisions for prizes and a chance to play in the Good Catch League Series. At the end of the season, the highest-scoring nursing unit is declared League Champion.
No matter what spin you put on it, are 23,000 catches something to brag about?
Not all reports are about risks to patient safety, and a lot are duplicates, says Summers. Multiple reports show prevailing problem areas and identify opportunities for patient care improvement. We all develop work-arounds that seem easier than trying to change the system, make problems fade into the background. Were nurturing a heightened awareness for improvement. The more they report, the more they notice. Staff learn they have the power to make a change.
She and Mick predict the longer the program lasts, the more the numbers will increase.
Any hospital can replicate the programs premise, says Summers, and its remarkably cost effective. With user-friendly software, it takes less than three minutes to enter a report, anonymously if desired, from any hospital computer. Entries are also reviewed in end of shift reports. No extra staff is required, and data is collected and processed by the Quality Improvement department. The cost of pizza, awards and the Good Catch pins is minimal.
Good Catch has changed the organizational culture, and evolved to encompass all employees and beyond. For example, after nurses reported leaking IV ports to a manufacturer, the company reviewed and revised its welding process.
What started as patient safety has blossomed to quality of patient care processes, says Mick. We can look at every step in a process to see cause, effects and improvements. Its now open to all employees, and [they participate] because of the excitement of the program.