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A new system that encourages every clinician to report situations that put patients at risk appears to be succeeding. Within 24 months, the new program, based at Johns Hopkins Medicine, in Baltimore, distributed 27 so-called “Good Catch Awards” to clinicians who reported situations that resulted in changes that were potentially lifesaving, including a national recall of improperly labeled drugs that had caused look-alike medication errors.

The concept of the program is based on the idea that one person is rarely at fault; rather, it is a faulty system, said Justin Hamrick, MD, a third-year anesthesia resident at the institution. As a result, raising concerns becomes part of protecting every person in that system and not blaming any individual. “It’s rare that it’s a particular person who is a problem; it’s usually the system that’s the problem,” Dr. Hamrick said. Since the hospital implemented the Good Catch Award program, the number of electronic reports submitted to the Patient Safety Network has increased by “a lot,” according to Dr. Hamrick, who has not yet formally tracked the difference.

Most of the incidents were what the researchers called “near misses,” in which patients were not harmed. About 5% to 10% of the incidents reported were considered to have caused harm to patients. “Most of the incidents were unsafe conditions that [could] have caused harm, but didn’t reach the patient,” Dr. Hamrick told Anesthesiology News. These incidents often are not reported because the risk is less obvious, but it still exists, he said. “These are the incidents we wanted to capture, before a patient was actually harmed.”

Dr. Hamrick and his colleagues presented details of the program at the 2011 annual meeting of the International Anesthesia Research Society (S-120), including examples of errors that were caught and rectified as a result of the new program. For instance, one clinician reported a situation in which a patient almost received an incorrect medication.

...The next step, Dr. Stoelting said, would be to install a national database into which every hospital must report all errors and so-called near misses, so that everyone can learn from each other. “I don’t see the Good Catch program really solving the problem of knowing the number of adverse events on a national level,” Dr. Stoelting told Anesthesiology News. Currently, he said, voluntary registries for particular types of incidents, such as postoperative blindness, do not capture everything out there and therefore miss many opportunities for improvement.