A near miss is an event or situation that could have resulted in injury, but it did not reach the patient, either by chance or through timely intervention.
What is a good catch?
While a near-miss event could have caused harm to a patient, a good catch is when a health care worker identifies a situation and prevents the potential harm from occurring.
Examples of a near miss:
- During medication administration, when performing the barcode scanning of the vial, the nurse identified the incorrect medication was removed from the Pyxis. The potential medication error is avoided due to the barcode scanning of the vial.
- The wrong food tray is delivered to a patient’s room who has orders to have nothing by mouth, or “NPO.” The patient notifies the patient care technician about the mistake.
Examples of a good catch:
- During medication administration, the nurse identifies the incorrect medication was removed from the Pyxis when performing the five rights of medication administration. The potential medication error is avoided due to the nurse verifying the medication according to best practice.
- A patient care technician identifies the wrong food tray is delivered to a patient with orders to have nothing by mouth, or “NPO.” The food tray is removed from the room before the patient begins eating.
How does Quality & Patient Safety identify near misses and good catches?
All RL Datix reports ask if the event was a good catch, and severity level of harm score for a near miss is assigned to the event once investigation is complete.
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Why are near misses and good catches important
They:
- Promote staff empowerment, transparency and an overall improvement in culture of safety.
- Identify risk within the organization that could impact other patients.
- Allow for proactive action planning and change to processes versus reactive action planning.
How do you hear about good catches in UTMB?
The Monthly Patient Safety Report distributed by Dr. Gulshan Sharma, SVP and CMO, shares a Good Catch story selected by the Patient Safety Department.
Next time you prevent patient harm, don’t forget to submit the RL Datix event report. Your actions could make a difference in how we deliver patient care.
—Submitted by Tina Thomas
Associate director, Quality Management & Patient Safety
Department of Quality Management