Best Practices: Making a "Great Catch" for Patient Safety - Crozer-Keystone Health System - PA

Best Practices: Making a "Great Catch" for Patient Safety

Last year, members of the Crozer-Keystone Transformation of the OR (TOR) Committee participated in a regional initiative to prevent Wrong Site Surgery (WSS) sponsored by the ECRI Institute, a federally designated patient safety organization. The Crozer-Keystone team, led by Max Santiago, PhD, RN, Director, Surgical Services, Ambulatory Services and Short Procedures Unit at Taylor Hospital, conducted a self assessment of the processes in place at CKHS facilities to prevent wrong site surgery.

“As a system, our volume of wrong site/wrong procedure issues has been very low for the past seven years, especially compared to other health systems in the same size range,” says Santiago. 

“We knew that every day our staff were catching errors in the normal course of their work and correcting situations before they led to serious errors,” explains Eileen Young, MSN, RN, CKHS Assistant Vice President of Clinical Utilization and Outcomes, and leader of the CKHS TOR Committee. “What we really didn’t know was any detail about those catches or how often they were occurring.”

We needed a mechanism to capture this information and, at the same time, recognize and reward staff for their good work,” notes Santiago.

The answer?  The Great Catch program.

What’s a Great Catch?

A “great catch” or “near miss” is an action on the part of a peri-operative team member that saved a patient from harm. These actions are often taken by team members with a keen sense of situational awareness and through the use of forcing functions like checklists.

Near Miss Events occur at a much higher frequency than actual adverse events or patient care errors. They are known to the individual who caught them, but may be unrecognized by the peri-operative team or its leaders.

How Great Catch Works

Great Catch was implemented system wide in all peri-operative areas in December 2008.

  • All peri-operative team members, staff and physicians alike, participate by identifying every “great catch” made personally or by a fellow team member, no matter how large or small.
  • Cards are provided where team members can provide information about the great catch they discovered.
  • Each great catch is posted on a display board located visibly in each peri-operative area.
  • Peri-operative team members are recognized formally and openly each time they make a great catch. They are presented with a special pin for their first Great Catch.
  • Great Catches are reviewed quarterly for “Great Catch of the Quarter” recognition awarded for the most significant catch.
  • All Great Catches are discussed and recommended for further departmental action by the system wide TOR group.

“Great Catch allows us to focus on the positive opportunities to improve patient safety rather than focus on the negative consequence of patient harm,” notes Santiago. “The staff has fully embraced the program because they understand that it is positive, not punitive, and has already led to improvements.”


By the end of the second quarter of 2009, over 80 “Great Catches” have been identified The “Great Catches” ranged from documents on the wrong patient chart to positioning a patient on the wrong side for a surgical procedure.

“Over half of the great catches we collected in just the first quarter had a potential for Wrong Site Surgery -- wrong patient, wrong procedure or wrong side,” notes Young, who spearheads the Great Catch program. “Last year, we modified our policy for scheduling a surgical procedure to include both a verbal and written notification of patient and procedure at the time the surgery is scheduled. We also rewrote our universal protocol policy to include an interactive timeout in the OR just prior to surgery. Still, it was very evident that these processes weren’t enough. Information was coming to us incorrectly from the surgeon’s office, and it became clear that we needed to collaborate with the staff in the surgeon’s offices to further improve the process and protect patients from harm caused by WSS.”

Young began by scheduling meetings between appropriate hospital staff and all surgical offices of the CKHS network physicians. Together, they discuss ways that the schedulers obtain information for scheduling surgery and identify areas of the process that need to be strengthened to ensure that all information is correct. “Once we’ve completed these meetings, we will use the collective wisdom of the group to build a best practice,” says Young, noting that the group has found an example of a strong practice already in use at two offices involving a three-way face-to-face confirmation between the surgeon, patient and scheduler.

“This is just one example of process improvement that can come out of the Great Catch program,” she adds. “Our thanks go to the staff who have to take an extra step to report the ‘little things’ they catch every day. The real reward is seeing how this information is used to improve patient safety in the OR.”

“Great Catch is a very effective tool for keeping patient safety number one in people’s minds,” says Santiago. “The staff really takes pride in their contributions as well as the validation and recognition they receive in front of their peers.”

Recently, Regina Jones, surgical technician in the OR at Crozer, received the first “Great Catch of the Quarter” award for catching a patient positioned on the wrong side for a surgical procedure and stopping the procedure just as it was about to start.

“We expect to continue learning from the other types of Great Catches made by our peri-op team as we continue working to ensure our patients have a safe surgical experience,” says Young. The team believes it would benefit the health system as well as patients to expand the Great Catch program beyond the peri-operative arena.

CKHS Great Catch Team

Eileen Young, MSN, RN, Team Leader

Fran Ancone, RN, Shift Supervisor, OR, Crozer

Olesh Babiak, MD, Chair, Anesthesia, Crozer

Mary Frances Brennan, RN, Director, Surgical Services, DCMH

Allen Gabroy, MD, Chair, Surgery, Taylor

William Isaacson, MD, Chair, Anesthesia, Taylor

Mary Kopp, RN, Director, PACU, Crozer

Deborah Lippman, MD, Anesthesia, DCMH

SueAnne Machemer, RN, Director, Short Procedure Unit, Crozer

William Mannella, MD, Chair, Surgery, Crozer

David McCloskey, MD, Chair, Surgery, DCMH

Craig Muetterties, MD, Anesthesiology, Springfield

Richard Pacitti, PharmD, Clinical Manager, Pharmacy, CKHS

Linda Palma, RN, CEN, CNOR, EBM Program Nurse, DCMH

Maximillian Santiago, PhD, RN, Director, Surgical Services, Taylor

Janice Simons, RN, Director, Surgical Services, Springfield

Connie Sonder, RN, BSN, MBA, Administrative Director, Nursing Services, Crozer

Al Varady, RN, Practice Manager, Department of Surgery, Crozer