“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” So said Dr. Lucian Leape, an internationally recognized leader in the patient safety movement, in testimony before the U. S. Congress 18 years ago.
According to the Joint Commission (Safety Culture Shattering the Myths of Perfection and Punishment, Joint Commission, 2017-04-27), encouraging the reporting and investigating of errors or close calls is essential to learning from the events and preventing future errors and patient harm. To create an open and fair environment that will improve patient safety and prevent future mistakes, two key myths must be dispelled:
- The perfection myth: If people try hard enough, they will not make any errors.
- The punishment myth: If we punish people when they make errors, they will make fewer of them.
University of Maryland Shore Regional Health models a culture of safety as defined by the Agency for Healthcare Research and Quality (AHRQ): “… in which healthcare professionals are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before harm occurs; and systems are in place to enable staff to learn from errors and near-misses and prevent recurrence” (AHRQ PSNet Safety Culture 2014).
Jean Seiler, RN, Clinical Quality Coordinator and Patient Safety Officer
A key Patient Safety initiative at UM Shore Regional Health is Good Catch (Near Miss), a recognition and reward program under the auspices of CELEBRATE WITH HEART. According to Jean Seiler, RN, clinical quality coordinator and patient safety officer, thanks to team members reporting near-miss events through RL 6, she and Risk Management are now receiving up to 10 reports per month in which an error of potential for harm was identified and corrected before it reached the patient.
“These reports are extremely helpful in enabling us to make adjustments to system process that will further support patient safety,” says Seiler. “We’d love to receive more, and we are encouraging team members to realize that by reporting an error before it reaches the patient, you can help others avoid similar errors.”
Good Catch reports will soon be factored into UM Shore Regional Health’s Celebrate With Heart Recognition and Reward Points Program. “For right now, the most important thing for now is for everyone to understand that there is no penalty for reporting an error,” Seiler says. “Our mission is to protect patients from harm and each additional ‘Good Catch’ will help us achieve our goal of ZERO harm.”
Seiler also emphasizes that March 11-17 is National Patient Safety Week, and that the UMMS Culture of Safety Survey will be posted on the intranet by mid-week. Be on the lookout for an email with the link.
For more information about Patient Safety and the Good Catch program, contact Seiler, 410-810-5192 (Chestertown), 410-822-1000, ext. 5136 (Easton/Dorchester) or firstname.lastname@example.org.