Health PEI Good Catch Award Recipients
The Good Catch Award recognizes staff and physicians who identify and report "near misses" or "good catches," and make changes to improve the quality and safety of the health care system. Awards are presented by the Quality and Risk Management Team.
Everyone is encouraged to take a proactive approach to quality improvement and report near misses before they become actual events.
Awards were presented to the following recipients:
Pharmacy and Emergency Department Nursing Staff, KCMH
A patient who was admitted to KCMH from the emergency department was administered her home medications while in the emergency department. Since pharmacy had not dispensed these medications, they were not documented in the usual way on the MAR. Amy Carpenter, Pharmacist, saw that the patient had taken the home medications and prevented administration of a second dose. To prevent this from happening again, a “cheat sheet” on how to document when a patient receives their home medications while in the emergency department has been developed.
Community Mental Health
A patient was discharged from Inpatient Mental Health with a follow up plan that included connecting with Community Mental Health. The patient's discharge guide that was forwarded to the Outreach Team contained an incorrect date for the next medication date. Staff from outreach was not able to directly access information and had to go to Inpatient Mental Health to obtain the correct date. In order to help prevent similar situations from occurring, staff was cross-trained in using the two applicable Electronic Health Record Systems. There was also a specific form created for common clients to track dates of medication administration.
Maintenance Department, QEH
When a visitor recently asked about the safety of electrical outlets in patient rooms, staff of QEH Maintenance Department were quick to respond. What they discovered was that since the QEH was built, standards have changed and improved but the outlets did not meet today’s standards. Although the QEH was not required to upgrade immediately to today’s standards, the Maintenance Department took quick action nonetheless. They reported the issue to the Provincial Chief Electrical Inspector and sent out a hospital wide memorandum to inform staff not to use these receptacles until they had been replaced. They also rolled out an action plan to have all receptacles replaced with ground fault interrupters by the end of December 2015 and remain on target for completion.
Nuclear Medicine Department, QEH
Nuclear Medicine staff was able to identify an error in patient data by conscientiously using the Required Organizational Practice (ROP) of "two patient identifiers" as part of their normal routine. Staff followed through with the physician’s office to obtain the correct documentation prior to the exam being carried out. We recognize the efforts of Nuclear Medicine staff for consistently following this ROP and acknowledge the positive impact for the patient. Plans are to promote this practice through the Provincial Diagnostic Imaging (DI) Leadership Committee, DI Quality Team, and across the health system.
After a potential spread of a communicable disease, the staff collaborated together to explore and implement strategies to reduce the likelihood of an event. Through the collaboration with nursing, infection control, physicians, employee health, senior leadership, and risk management: follow up actions consisted of a change to the cleaning processes across all provincial sites and ensuring all staff immunizations in the dialysis are up to date.
Stewart Memorial Home
After a resident experienced a near miss fall, the staff collaborated together to explore and implement strategies to reduce the likelihood of a fall event. Through the collaboration with the resident, family, nursing, allied health and support services, staff follow-up actions consisted of modifying the residents' environment to eliminate potential hazards, completing a full medication review and updating the care plan on these changes.