The Importance of Microsystems

Poniatowski and colleagues⁶ described organizations as macrosystems that are built upon many interrelated microsystems. Most actual or potential errors in a hospital setting, which directly affect patient care outcomes and negatively affect patient safety, likely occur at the microsystem level.^7,8 Therefore, to capture safety concerns at the time they are identified, it would be necessary for the program to engage frontline employees of inpatient nursing units as reliable sources of information.^9,10,11 However, acquiring reports from the microsystem level has been hindered by several factors. A study of nurses’ medication error reporting revealed four factors that explain why employees may not report errors: (1) fear, (2) disagreement over whether an error occurred, (3) administrative responses to errors, and (4) the effort required to report an error.¹²

Fear

In order to overcome employee fears and concerns associated with reporting, a culture of trust must be promoted within an organization.^7,8,9 This can best be accomplished by eliminating the possibility of assigning blame or initiating disciplinary action related to reporting.^7,13,14,15 Employees must be made to feel safe to report so that safety concerns can be identified and the systems can be strengthened.^10,16,17

In close call reporting, employees are asked to report situations for which they have already effectively intervened to prevent error. The definition of a close call, as found on the reporting tool, is “a situation that does not cause harm nor reach the patient.”⁵ The UTCCRS was designed as an anonymous reporting system to protect employees’ identity.¹³ Reports are screened outside the hospital’s risk and quality department by an impartial third party group of experts. Names, room numbers, medical record numbers, and any other identifying information are scrubbed from reports (if they have been entered by an employee). The system does not allow individual reporters to be identified or contacted. However, when a report is entered, a unique tracking number is automatically generated. The employee can use this unique tracking number to re-access the system and review followup notes if they desire feedback (Appendix 1).

Defining Actual and Potential Errors

To ensure that appropriate information would be submitted to UTCCRS, it was important to clearly define close calls (“Good Catches”) in the educational component of the program. Hritz, et al.,¹⁸ recommended that reporting systems and improvement interventions continually focus on building an awareness of the occurrence of errors through identification and reporting. To address this recommendation, examples of reports that demonstrated the differences between actual and potential errors were developed, and a list of potential error examples was created as a reference tool. The educational plan incorporated the instruments as exemplars and handouts.

The Importance of Executive Leadership Support

Initiatives led by hospital executives to improve an organization’s culture of patient safety can result in a profound and lasting change in the organization’s safety culture.^19,20 Leaders need to visibly guide and support staff through reporting systems that involve recognition and rewards.²¹ Therefore, mechanisms for administrative leaders to show support and motivate employees are essential to the Good Catch Program. Continual recognition of progress, shared safety success stories, and celebrations of achievements were incorporated into the program design. Building recognition and reward from executive leaders, including associated financial support, was therefore identified as another important program component.

Recognition of employees’ personal ability to effect change was also identified. Plans to recognize patient safety champions with safety award certificates and “Most Valuable Player” (MVP) recognition were included in program design. This was recognized as a needed improvement based on feedback from employees and executives after the original launch of UTCCRS. Barriers and interventions to surpass them are summarized in Table 1.

Table 1

Summary of barriers and interventions.

The Good Catch Program

A baseball theme was used to organize inpatient nursing units into teams and group them in one of four Divisions of an Inpatient Nursing League. A report accepted into the UTCCRS resulted in a point for the team. A unit code generated points for each team, while maintaining the reporter’s anonymity. The team and “game” approach engaged frontline staff in a fun, friendly competition on inpatient nursing units as they reported Good Catches identified in daily practice.

As each team joined the league, unit-based in-services were provided using a PowerPoint^™ presentation and handouts that included definitions and examples of close calls. Information provided during the educational sessions included definitions of safety and preventable harm; descriptions of a systems view of errors; theories and perspectives about errors in health care; description of UTCCRS with instructions for entering data; and examples of advances in patient safety and human factors in design.

To maintain the program’s baseball theme, close calls were renamed “Good Catches.” Each unit decided on a team name, and representatives from each team served on a workgroup that met as needed to address “game” strategies. Creative team names included: SCRUBS: Safety Created Regularly & Uniformly by Staff; PEDI: People Effectively Decreasing Incidents; OOPS: Outstanding Outcomes in Patient Safety; The Hazard Hunters; STOPS: Staff Thinking of Patient Safety; and The Awareness All-stars.

Quality Improvement Department representatives and administrators of the UTCCRS were included as workgroup members. Team representatives were assigned the important position of Patient Safety Champion and were given responsibilities to facilitate communication of program information to their team members. Weekly scoreboards were e-mailed to representatives for posting on the units. A friendly competition between units was promoted by encouraging team members to submit reports and earn points for their team.

The team in each Division that entered the greatest number of Good Catch reports during a “game” was recognized in the institution’s Nursing News & Information weekly newsletter and awarded a pizza party. In addition, MVPs were identified on each team, and each received a patient safety champion award certificate signed by executive leadership. An Inpatient League World Series is currently in the planning stages. The World Series event will provide a forum for organizational level recognition of employee participation in the Good Catch safety initiative.

Executive Leadership Support

The Vice President of Nursing served as the Inpatient League Commissioner to ensure that executive leadership was provided. Four department directors served as head coaches for each Division to enhance visible administrative support for the program. Every 6 months, a new Division of four to five nursing units was formed. Education and mentorship were provided for all team members until all four Divisions were participating in the program.

The Vice President of Nursing visited each unit approximately 4 months after they joined the program and distributed Good Catch pins to participating team members. Team members prepared patient safety storyboards and shared information about the different types of Good Catches. Several teams had t-shirts made with a team logo and wore baseball caps during the unit visit. One team decorated the staff lounge as a dugout. In addition, incentives for nurses (e.g., “Safety Awards”) were sponsored and promoted by executive leadership to acknowledge individual nurses as patient safety champions during each 6-month game.

Categories Reported in Good Catch

The reporting categories in UTCCRS are not mandatory; the reporter can choose one category or many categories or even not to categorize. The total count of categories (26,622) was higher than the total number of reports received (25,921) because reporters chose several categories in some reports (Figure 2).

Figure 2

UTCCRS “Good Catch Report,” count by category: December 2005–July 2007.

Contributing Factors

The contributing factors list in the UTCCRS was developed in an extensive consensus-building exercise as the system was developed¹³ (Appendix 2). The total count of factors identified in Figure 3 (29,273) is greater than the total number of reports received (25,921) (Figure 1) because there are no mandatory reporting fields, and reporters might have chosen more than one (Figure 3).

Figure 3

UTCCRS “Good Catch Report,” count by contributing factor: December 2005–July 2007.

Sensemaking of Good Catches

Battles, et al., described safety data as requiring “sensemaking” conversations based on data acquired from detection tools, such as reporting mechanisms.²² Sensemaking also assists in categorizing and prioritizing the risk knowledge that comes from reported events. This essential component of an organization’s safety plan is necessary to create a proactive culture and proactive intervention for safety.¹⁰ Close calls—or good catches—are included in the safety data that contribute to an institution’s safety plan and interventions.

Aggregating themes from the Good Catch Program has informed several quality initiatives. The Good Catch program has generated a number of safety interventions based upon collected data and the “sense” made of these reports. Many of the reports provided data that confirmed systems mechanisms were in place to prevent actual errors from occurring. Examples of system error prevention mechanisms include: medication administration record (MAR) reconciliation; 8-, 12-, or 24-hour chart checks; and increasing double-checks on reported high-alert medications. Multidisciplinary teams have utilized good catch data to generate short- and long-term quality improvement projects.

In a health care organization, a large collection of good catches provides challenges. The first challenge is to familiarize the organization with the volume, purposes, and nature of safety reporting. The number of reports is daunting when each one is considered individually, and certainly few organizations maintain the resources to respond equally to each report. Battles, et al., describe the analytical tools necessary to assist staff working with such data to “overcome the limitations of the individual mind” so sense can be made of larger data sets.²² After “sense” has been made, the challenge is to provide interventions based on such reports, so that changes can be made to reduce system-level vulnerabilities found in the data.¹⁰

Challenges

Initially, many of the teams expressed concerns by questioning whether a high number of good catches might “look bad” for a unit. Positive feedback was provided to assure teams that higher numbers of submitted reports supported a greater focus on patient safety. Also, because historically reports were submitted only when an actual error had occurred, a “change in thinking” was required. Some teams raised questions about why units with more submitted reports were being recognized, while units that just “fixed” concerns but did not report them were not being rewarded. This question provided the opportunity to educate employees that although they continually intervened to ensure safe care, the “fixes” needed to be reported so that systems issues could be identified and addressed.

Program coordinators and administrative leadership affirmed that positive recognition was being provided to units that were submitting a high volume of reports. Reports were communicated as “nursing interventions for patient safety” and close call reporting was promoted as an opportunity for employees to document their important role in the front line of patient safety.

By successfully increasing the numbers of reports submitted to the University of Texas Close Call Reporting System, the Good Catch program has provided a supporting mechanism for the organization to systematically and effectively learn from safety interventions implemented on the front line. Gaining insight about areas of potential vulnerability has allowed the organization to be proactive with interventions to eliminate risk for potential errors and to decrease the possibility of an actual error occurring. Each Good Catch has contributed to safer patient care.