Due October 15th, 2009 at 4:00 pm via e-mail to
khannah@rha-central.mb.ca
To be awarded during
Canadian Patient Safety Week
November 2 - 6, 2009
Have you made a “good catch” that could have resulted in an incident or critical incident and in turn led to safer practice and shared learning? If so, the Manitoba Institute for Patient Safety wants to hear from you!
A “good catch” is defined as an event or circumstance which has the potential to cause an incident or critical incident but the incident did not actually occur due to corrective action and/or timely intervention. It provides an opportunity to learn proactively from the experience. Organizations may also define these as near misses or close calls.
All employees, physicians and students in Manitoba’s health care system are invited to submit a description of a “good catch” that resulted in improvements in patient safety and shared learning.
Good catch examples may include but are not limited to the following:
- A public health nurse prepares to give a Hepatitis B vaccine to a child in grade four. She prepares the medication as outlined on the vial. Just prior to giving the vaccine, she notes the wrong dosage is listed on the vial. The dosage is for an adult. Pharmacy is notified and steps are taken to prevent similar situations in the future.
- A nurse is checking the unit dose medications for a patient. The patient has an order for Lasix 20 mg orally. The unit dose package contains Losec 20 mg orally.
The patient is not on Losec. Pharmacy is notified and the correct drug is provided to the patient. A review is done on storage/packaging of look-a-like/sound-a-like
medications and changes are made to the storage/packaging of these medications. - A lab technologist is to draw blood from a patient “Jane Doe’ in Room 2, bed 2. The lab technologist asks the patient if she is “Jane Doe” to which the patient answers by nodding her head. The lab technologist prepares to take the patient’s blood and at the last minute double checks the patient’s identification on her ID wristband which identified a different patient’s name. It was later noted that the patient is hard of hearing and just nodded her head to be pleasant. “Jane Doe” had been moved to another room and the lab had not been notified. The review highlighted the need for consistent processes related to patient identification.
The top three submissions, based on the criteria outlined below, will be acknowledged during Canadian Patient Safety Week, November 2 - 6th, 2009.
Your submission is required by October 15th, 2009, at 4:00 pm.
Submission guidelines:
Cover page including:
- Names
- Title/Occupation
- Organization
- Title of Submission
- Daytime Phone Number
- Email Address
- Fax Number
Description of “good catch”, maximum 3 pages not including cover page (1350 words), including:
- Situation
- Background
- Assessment
- Action taken
- Lessons learned
- Changes
Examples of review criteria:
- Statement of the extent of the problem
- Leading / Best practice evidence
- Multidisciplinary process
- Description of review process/tools used to proactively assess a situation (may include processes such as failure mode effects analysis)
- Change management process used
- Evidence of incorporation of improvement into daily practice, including how the changes/improvements were communicated
- Evidence of expected improvements in patient safety as a result of change
- Evidence of broader applicability within the site, region or province
If you require further information please contact the person listed below.
Please submit your information by October 15, 2009 at 4:00 pm via e-mail to: Kristine Hannah, Regional Program Director, Quality Improvement & Risk Management
khannah@rha-central.mb.ca / phone 1-204-428-2744