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.
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