Mistakes happen. In healthcare, however, mistakes can have dire repercussions and have to be avoided. As the World Health Organization asserts, “delivering safer care in complex, pressurized and fast-moving environments is one of the greatest challenges facing health care today.”1 Facilities understand this challenge and are seeking ways to improve patient safety by looking more closely at where they fall short.
In the wake of the Patient Safety and Quality Improvement Act of 2005, national attention has increasingly focused on adverse-event reporting as a means of identifying systems changes to improve patient safety.2 Though experts view near misses as possibly the best predictors of medical error, these are markedly underreported. Renewed efforts have been made by facilities to shift the tone around reporting close calls to be more positive and proactive after the “Good Catch” model piloted by MD Anderson in 2005.
The success of this program is attributed to the use of more positive terminology from “close calls” and “near misses” to “good catches,” shifting the focus from fear and punishment to encouragement and reward. It has been adopted by numerous organizations and grown into a “non-punitive change agent for new processes, improved clinical practice standards, and renewed the culture of proactive patient safety awareness.”3 Bob Massey, Ph.D., registered nurse, assistant professor, and director of clinical nursing at MD Anderson says, “We catch potential or actual errors, analyze what happened, and then correct the action, process, or system — all before it affects the patient.”3
Institutions receiving “Good Catch” awards are not being recognized merely for their efforts in reporting hazards, but in leading sustainable initiatives to improve patient safety. The ownership is on the facility’s leadership to correct the hazards identified by clinicians, including design-oriented corrections to the physical clinical environment, policy or procedure modifications, additional training, or standardizing communication systems. Depending on which form of correction is needed, the required resources, staff time, and financial expenditure may vary widely.4
In response, facilities are actively researching tools and processes that can address the identified issues; Technology is offering these facilities tremendous resources to help catch and mitigate many such hazards. One Medical Passport, a comprehensive medical software solution, was founded by a clinician very aware of these current objectives and designed its products in direct response to the shortcomings and challenges observed in surgical facilities.
Incomplete Medical Histories
- One Medical Passport’s complete, comprehensive, and easily assessable online medical histories ensure the patient’s medical team has the information they need, when they need it.
High Risk Patients
- One Medical Passport’s customized risk assessments alert facilities to risks and conditions needed to be assessed more closely well in advance of the day of surgery. By identifying criteria to be flagged in patients’ medical histories, facilities ensure pre-op nurses and anesthetists review the necessary charts in a timely manner.
- Automated pre-op diagnostic testing and assessments better screen for risk factors including sleep apnea, deep vein thrombosis, allergies, pain assessment, and fall risks prior to admission. This targeted information helps anesthesiologists and surgeons determine risk levels for patients with comorbidities and alerts staff to special preparations needed in the O.R.
The key to real improvements in these facilities are solutions that are sustainable and systemic. One Medical Passport’s online tools were created with these goals in mind – offering consistency, comprehensive management and quality assurance to avoid many of these “good catches” in the first place and help facilities problem solve issues identified and find solutions that can be incorporated for long term success.
Since the publication of To Err Is Human in 1999, which exposed the shortcomings in quality and safety in U.S. healthcare, medical facilities have made great efforts to address many of these issues. One Medical Passport is helping them go further. As the book asserts, “the problem is not bad people in health care–it is that good people are working in bad systems that need to be made safer.”5 One Medical Passport provides online solutions to allow medical professionals to work at their best to ensure patient safety and quality care.
This article was brought to you by One Medical Passport. Please feel free to forward it on to colleagues or associates or find out more about our cloud-based solution for better perioperative care at https://www.onemedicalpassport.com/
- Patient Safety: Making health care safer. World Health Organization. 2017 http://apps.who.int/iris/bitstream/10665/255507/1/WHO-HIS-SDS-2017.11-eng.pdf?ua=1
- Scott, D. R., et al. A novel approach to increase residents’ involvement in reporting adverse events. https://www.ncbi.nlm.nih.gov/pubmed/21512369
- Penne, Julie. Paying attention leads to better practices. MD Anderson Cancer Center. Spring 2011. https://www.mdanderson.org/publications/conquest/spring-2011/good-catch-program.html
- Herzer, Kurt, et al. Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards. PMC. Jan 11, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888507/
- To Err is Human: Building a Safer Health System. Institute of Medicine. https://www.ncbi.nlm.nih.gov/pubmed/25077248