SPRINGFIELD - Crozer-Keystone Health System received the 2009 Delaware Valley Patient Safety Award for creating the “Great Catch” program. The initiative provides a simple way for staff to report a “near-miss event” and educates surgical physicians and staff about risk reduction strategies.

In recognition, the Health Care Improvement Foundation awarded Crozer-Keystone a grant of $5,000 to help support future patient safety initiatives. The award was presented at the 2009 Annual Meeting of the Delaware Valley Healthcare Council of HAP in Philadelphia in October. 

A 10-member committee of quality and patient safety leaders from the Drexel University School of Public Health, ECRI Institute, Healthcare Performance Improvement, LLC, The Hospital & Healthsystem Association of Pennsylvania, Independence Blue Cross, the Institute for Safe Medication Practices, the Pennsylvania Patient Safety Authority, the Philadelphia Department of Public Health, the U.S. Department of Health and Human Services, and VHA East Coast chose the patient safety award recipient and finalists from 38 nominated projects. Selection criteria included significant, sustained safety improvement; organization commitment; innovation; and ease of replication by other hospitals and health care providers.

“The Great Catch program has been an outstanding system-wide, team effort. I congratulate everyone who has been involved in the implementation and continued success of the program on receiving this prestigious honor. This is a very important step in improving our culture of safety,” says Eric Dobkin, M.D., CKHS vice president of Quality and Patient Safety.

Delaware Valley Healthcare Council of HAP advocates for southeastern Pennsylvania hospital and health care-related organizations including more than 50 acute and specialty care hospitals and health systems, 30 facilities providing inpatient behavioral health services and 20 facilities providing rehabilitation. The Health Care Improvement Foundation is an independent, non-profit organization with a multi-dimensional focus on health care safety in southeast Pennsylvania.

The Origin of the Great Catch Program

Last year, members of the Crozer-Keystone Transformation of the OR (TOR) Committee participated in a regional initiative to prevent Wrong Site Surgery (WSS) sponsored by the ECRI Institute, a federally designated patient safety organization. The Crozer-Keystone team conducted a self-assessment of the processes in place at CKHS facilities to prevent wrong-site surgery.  

“We knew that every day our staff were catching errors in the normal course of their work and correcting situations before they reached the patient and could cause harm,” says Eileen Young, M.S.N., R.N., CKHS assistant vice president of Clinical Utilization and Outcomes, and leader of the CKHS TOR Committee. “What we really didn’t know was any detail about those great catches or how often they were occurring.” 

The team knew that it needed a mechanism to capture this information and, at the same time, recognize and reward staff for their good work. The answer? The Great Catch program. A “great catch” or “near miss” is an action on the part of a peri-operative team member that saved a patient from harm. These actions are often taken by team members with a keen sense of situational awareness and through the use of forcing functions like checklists.

Near-miss events occur at a much higher frequency than actual adverse events or patient care errors. They are known to the individual who caught them, but may be unrecognized by the peri-operative team or its leaders.

How Great Catch Works

Great Catch was implemented system wide in all peri-operative areas in December 2008. 

• All peri-operative team members, staff and physicians alike, participate by identifying every “great catch” made personally or by a fellow team member, no matter how large or small.
• Cards are provided where team members can provide information about the great catch they discovered.
• Each great catch is posted on a display board located visibly in each peri-operative area.
• Peri-operative team members are recognized formally and openly each time they make a great catch.  They are presented with a special pin for their first Great Catch.
• Great Catches are reviewed quarterly for “Great Catch of the Quarter. Recognition is awarded for the most significant catch.
• All Great Catches are discussed and recommended for further departmental action by the system wide TOR group.

Young says, “Last year, we modified our policy for scheduling a surgical procedure to include both a verbal and written notification of patient and procedure at the time the surgery is scheduled. We also rewrote our universal protocol policy to include an interactive timeout in the OR just prior to surgery. Still, it was very evident that these changes weren’t enough. Information was coming to us incorrectly from the surgeon’s office, and it became clear that we needed to collaborate with the staff in the surgeon’s offices to further improve the process and protect patients from harm caused by WSS.”

Meetings have been scheduled between appropriate hospital staff and all surgical offices of the CKHS network physicians. Together, they discuss ways that the schedulers obtain information for scheduling surgery and identify areas of the process that need to be strengthened to ensure that all information is correct.

“Once we’ve completed these meetings, we will use the collective wisdom of the group to build a best practice,” Young says, noting that the group has found an example of a strong practice already in use at two offices involving a three-way face-to-face confirmation between the surgeon, patient and scheduler.

“This is just one example of process improvement that can come out of the Great Catch program,” she adds. “Our thanks go to the staff who have to take an extra step to report the ‘little things’ they catch every day. The real reward is seeing how this information is used to improve patient safety in the OR.”