American Data Network Patient Safety Organization (ADNPSO) named its third quarter recipient of the Good Catch Award, presented to outstanding Arkansas healthcare workers striving to drive change and enhance patient safety through engagement in ADNPSO’s statewide near miss campaign.
The Good Catch campaign offers participating organizations opportunities to significantly increase near miss reporting, reveal process and system vulnerabilities, and develop and implement proactive data-driven improvement activities. The campaign is based on the belief that empowering hospital staff to speak up stands as one of the most impactful ways of fortifying a trustworthy organizational culture of safety. Essentially, a near miss or close call reported today could prevent an error from happening tomorrow.
Angie Powell, a pharmacist at Baxter Regional Medical Center in Mountain Home, received the individual Good Catch Award for the campaign’s third quarter. When a patient was ordered the anticoagulant, Warfarin, Powell noted the patient’s last INR was elevated at 5.5, above the threshold for anticoagulation therapy. Instead of dispensing the order, Powell requested another INR which resulted in a 9.25 reading. The order for Warfarin was discontinued, and Powell facilitated the order and administration of Vitamin K to treat the high INR. Powell’s questioning attitude and willingness to double check the INR measure prevented this patient from being unnecessarily treated with anticoagulation. Powell’s Good Catch was communicated to all pharmacists emphasizing the need to verify the INR before dosing.
Forty-three Arkansas hospitals are participating in the Good Catch campaign. As a result, they have reinvigorated their commitment to safety culture by reinstituting idle patient safety committees, engaging leadership, and improving communication between departments. By the end of the campaign’s third quarter, participating facilities had reported over 7,400 near misses collectively.
The Good Catch campaign is endorsed by the Arkansas Hospital Association, Arkansas Health Executives Forum, Arkansas Organization of Nurse Executives, Arkansas Association for Healthcare Quality and Arkansas Foundation for Medical Care. To learn more about the Good Catch program, click here.
American Data Network PSO, established in 2009, was the first federally designated Patient Safety Organization established in Arkansas and authorized to work with hospitals to improve patient care through voluntary reporting of patient safety events and professional analysis of shared data.
Infographic – The Anatomy of a Near Miss 