Good Catch: Finding Near Misses and Preventing Errors

A near miss is any error or potential error that is caught, purposely or by chance, before it reaches the patient. Besides potential causes of adverse events, near misses are opportunities for improvement because they highlight process deficits and are an avenue for continuous improvement. To use near misses for process improvement, an organization must first understand the near miss phenomenon. Although there is an expressed interest by healthcare organizations to collect this type of information, issues related to under-reporting, limited data collection, inability to have real-time reporting, appropriate response to the occurrence, and inability to create a non punitive culture have limited the collection of this type of information.

The Krasnoff Quality Management Institute (KQMI), in conjunction with the North Shore-Long Island Jewish Health System (NS-LIJHS), has created and successfully implemented a comprehensive Good Catch/Near Miss reporting program in 6 perioperative settings, using the Plan-Do-Check-Act (PDCA) methodology. The purpose of the program is to alert caregivers to potential errors through developing a process for increasing reporting of near misses by 100% within a blame-free framework. In addition, the implementation of the PDCA methodology for performance improvement assists in the identification of solutions to systemic potential errors.

KQMI collaborated with physicians and quality professionals at NS-LIJHS, to pilot test the Good Catch program in perioperative services in a large tertiary hospital discharging approx. 1600+ surgery patients monthly. During a 2 month period, perioperative staff reported 19 near misses. Subsequently, KQMI implemented anonymous focus group sessions in seven of ten hospitals in order to (1) understand the near miss phenomenon from the perioperative staff perspective; (2) develop a pragmatic definition of near miss; and (3) highlight reasons for underreporting of near misses. The qualitative information was aggregated and qualitative analyses were performed. The results used to create an anonymous reporting tool, a web-based database with real–time reporting. During the two month period after the implementation of the Good Catch program, perioperative staff reported 164 near misses- an eight fold increase compared to the pilot test. As a result of the successful and sustainable program, Good Catch was rolled out to another tertiary hospital and four community hospitals. Currently, 1,132 near misses have been reported throughout NS-LIJHS (July 2006-February 2008).

This methodology, grounded in PDCA and associated tools, illustrates how data obtained through the Good Catch program is used to prioritize issues and create pragmatic sustainable solutions to improve patient safety.