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Summary

In March of 2018, American Data Network PSO celebrated the achievements made by the  45 hospitals that participated in ADNPSO’s 2017 Good Catch Campaign. The pioneering organizations who participated in this study increased Near Miss reporting by 47% over baseline and provided concrete evidence of the learning that happens when Near Miss events are shared and studied. In September, ADNPSO checked in with the Good Catch hospitals to find out how their Near Miss programs are faring six months post-campaign. Forty-two percent of the hospitals responded, and here’s what we learned from them :

First of all, 100% of the hospitals responding to the follow-up survey confirm that their organization continues to hold up Near Miss reporting as a priority. Ongoing reporting and analysis of Near Miss events is viewed as a patient safety improvement strategy that works.

Sixty-three percent of those facilities report a decrease in overall patient safety incidents. And they attribute that improvement to corrections and initiatives established in response to lessons learned through Near Miss reporting. Read more in this article on a 6 month follow-up to ADN's Good Catch Campaign.

How to Implement Your Own Near Miss Campaign

Review Baseline Data and Set a Goal:  Take a look at your organization’s patient safety event data over a 12-month period. What overall volumes, trends and patterns do you see? Closely examine the near misses reported. Who reported them? What kinds of events were reported most often -- medication, communication? Note any trends revealed. Isolating near miss data by month will be helpful in setting a stretch-goal for increasing near miss reporting over time. When setting your goal, keep in mind that experts estimate that every clinical staff member is aware of or involved in no less than 3 near misses per year.

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Assess Opportunities for Reporting Improvement:  Near miss reporting needs to be quick, easy and accessible for frontline staff. Does your existing collection method (paper or electronic) facilitate ease? If not, consider introducing a simpler form, and make sure staff understand the significance of their role in the reporting process. Everyone needs a clear and identical definition for near miss as well as an understanding of plans for delivering and utilizing feedback.

To strengthen safety culture, you need to get a read on staff perceptions of the organization’s existing environment. AHRQ’s Hospital Survey on Patient Safety Culture can be integral to creating a profile for your organization’s approach to patient safety. Do you learn from your mistakes? Are staff comfortable reporting events when they happen? What do you do with feedback when you get it? Additionally, you may be able to gauge perceptions of strengths and barriers that impact reporting efforts through leadership rounds, huddles, and even interviews.

Obtain Senior Leadership Support:  Endorsement from the C-suite is essential to bringing physicians, managers, and frontline staff on board as well as securing resources for improvement efforts. When talking to senior leaders, it’s important to present baseline event reporting data and to help them understand how increased near miss reporting can translate into fewer adverse events. They need to be familiar with campaign goals, and they need to know who is going to be responsible for managing the campaign as well as what resources they are going to need.

Designate Oversight Team/Committee:  Examine your facility’s committee structure to either designate an existing team or form a new oversight team to manage the program. In addition to selecting a skilled facilitator to steer the team’s work, identify additional staff who, serving as change agents, can drive efforts to increase near miss reporting facility-wide. This group needs to be a multidisciplinary assembly of strong, well-respected staff leaders committed to leading by example.

Develop Action Plan:  Use findings revealed through reviews of the organization’s baseline data, Hospital Survey on Patient Safety Culture, and other assessments to develop strategies that address weaknesses and leverage strengths. What issues need to be considered in introducing a near miss campaign in your facility? Will staff be receptive or will they shy away? Are there clear problem areas that you need to prioritize?

The oversight team will need to establish a reporting process as well as a process that ensures a monthly review of near miss details and an evaluation of goal progression. Continuous review of qualitative and quantitative data will help identify opportunities to redesign systems and processes.

Design an internal reward and recognition program that will offer opportunities to fuel learning through shared success stories, celebrate achievements, and involve leadership.

A meaningful reward can be as simple as a certificate, newsletter spotlight, or personal Thank You note. The CEO of one organization participating in ADN PSO’s campaign announced in a facility-wide email that, for each quarter, the staff member reporting the best good catch would receive a paid day off!

Prepare for Launch:  Thorough staff education and consistent communication are essential to campaign success. Expose all frontline staff and physicians to near miss education and groom leaders, managers, and supervisors to serve as educators and encouragers within their areas. Again, everyone needs to know how to identify a near miss and how to report one when discovered.

Generating awareness and inspiring ongoing staff engagement will require the use of multiple channels of communication from newsletters and email alerts to safety huddles and leadership rounds. Work toward building a toolkit of educational resources and promotional materials that can be used to train staff and bolster engagement over the course of the campaign. Consider utilizing existing resources and creating some of your own tools like: screensavers, posters, infographics, tip clips, intranet banners and email signatures. ADN PSO even has a FREE toolkit for Good Catch Campaigns.

Sustain Momentum:  A monthly review of near miss reports, conducted by the oversight team, will help identify any areas where near miss reporting may be stalled or declining, and will prompt modification of strategies and interventions. Timely, relevant feedback is critical to keeping staff engaged at all organizational levels as is continuous implementation of the campaign rewards program. Take every opportunity to recognize patient safety champions and celebrate the individuals, departments, and teams who are using near miss analytics to take action that ultimately reduces risk and prevents patient harm.

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