Figure 3 • Good Catch Form Drop Box
disposition. Continuing to the patient’s
room, the patient began speaking incoherently and was displaying signs/symp-toms of a stroke. The transporter called
the rapid response team and it was
subsequently determined that the code
stroke team needed to be called. With
keen observation and full attention to
the patient’s needs and condition the
transporter was able to quickly recognize
changes in the patient’s health and notify
the appropriate personnel. The event
served as a strong reminder of the important task that our transporters have.
Good catch reporting and actual event
reporting within imaging has significantly
increased system wide since the project
began. Reporting of near misses went
from zero at the beginning of the program
to roughly 30 system wide monthly. Staff
also started reporting more actual events,
as they realized the importance of report-
ing both actual and near miss events.
The results reinforce the importance of
education as well as the importance of
leadership supporting a culture of safety
in which event reporting is non-punitive.
Sustaining the program takes continued
effort by all, including leadership at all
campuses and the front line patient safety
champions. To keep the importance of the
program at the forefront of leadership’s
mind, a weekly email is sent to the imaging
services directors detailing actual events
and good catches across all modalities and
campuses. There are also monthly updates
to a centralized online site which compiles
all of the data including actual events
reported, good catches, and our “What a
Great Catch” stories which we use to rec-
ognize staff for the month. See Table 1.
All near misses are followed up on
with the staff member who entered the
event. If the event is identified as a process
improvement opportunity, the process is
evaluated and revised to prevent the near
miss from happening again. Imaging staff
have progressed significantly because of
this culture shift, realizing there is inherent risk in everything they do and there are
many potential opportunities for failure.
Staff continue to look for good catches,
and are excited about reporting them. Of
course, sustaining the program requires a
move toward openness and accountability where the reporting of good catches is
clearly valued and rewarded.
1Wolf, Zane Robinson & Hughes, Ronda G.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG,
editor. Rockville. 2008.
2Report: Institute of Medicine. (1999). To err is
human. Washington, DC: National Academy of Sciences. Retrieved from http://site.
3Coyle G. Designing and implementing a close
call reporting system. Nursing Administration Quarterly 2005; 29( 1):57–62.
Janine Jones, RN, MBA is in charge of patient safety
for the WakeMed Health & Hospitals system. She has
eight years of experience in the field of patient safety.
She can be reached at firstname.lastname@example.org.
Michael Newman MHA, CRA, RT (R) is the clinical
operations manager over CT, interventional radiology,
ultrasound, and support staff at the WakeMed Raleigh
campus. He can be reached at email@example.com.
TABLE 1. Good Catch Program Report
Jul- 13 Aug- 13 Sep- 13 Oct- 13 Nov- 13 Dec- 13 Jan- 14 Feb- 14 Mar- 14 Apr- 14 May- 14 Jun- 14 Jul- 14
Imaging Services Good Catch, Raleigh campus
July 2013 - July 2014
Source: Risk Management