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Safety Culture Includes “Good Catches”

  • October 7, 2015
  • RPh on the Go

pill safety pharmacist hospitalHospitals working to recognize interceptions of medication errors or other safety related issues before they make it to the patient show that doing the right thing can be personally rewarding while supporting the hospital’s effort to continuously improve patient care.

Clinical Pharmacy Coordinator at Memorial Medical Center in Modesto, California, Pamela Lenhart, describes a recent good catch:

“We had two different strengths of Tamiflu that we found because we had the bottles mixed up in the bed in the main pharmacy. The hospital staff members who report incidents like these are congratulated in front of their coworkers and eligible for modest prizes.”

Beyond simple recognition, if it is a really good catch, the boss will provide some sort of small reward, such as a gift card for coffee or the cafeteria.

The good catch program at her hospital started about two years ago in the emergency department, later expanding to all units in the hospital.

The program is designed to recognize people who pay attention and find these things, as well as educate staff on what to look for. If different strengths of medication are found together in the automated dispensing unit, then everyone begins to look out for that.

The program tracks all the good catches on the spreadsheet, which is reviewed every month by the hospital’s quality management department.

A similar program also exists at the University of Vermont medical Center in Burlington. Staff members report good catches using an online form. The program began several years ago, and every month gives one employee a $100 gift card, a good catch pan, and a mention in the hospital’s newsletter. Anyone who wins the monthly prize becomes eligible for an annual prize of $500 as well as additional recognition in the newsletter.

Even though it’s not a large award, there’s a certain amount of prestige in getting it, and people are appreciative. Pharmacists and pharmacy technicians are chosen fairly regularly for the monthly awards, but about four years ago, the hospital chose to start a departmental good catch program specifically for the pharmacy that provides a certificate and a $25 gift card to a pharmacy staff member every month.

These programs encourage reporting an increase staff awareness of how the reports can improve patient safety.

In the Vermont program, one pharmacy technician discovered a batch of cardioplegia solution purchase from a compounding pharmacy actually contained the wrong base solutions. Starting programs like this is not only designs to help keep pharmacists and hospitals more accountable, it helps keep patients healthier and improves overall quality of care.

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