How to boost safety by highlighting the accidents that didn’t happen

Christine Devine of Avon had just returned home after several days in the hospital when she filled her prescription for blood pressure pills and discovered they had come in a blister pack instead of the usual plastic bottle.

Problem is, Devine, who is 83, hates blister packs. “They’re hard to open, because of the arthritis in her fingers, so she just popped them out of the blisters and put them in the old bottle,” said her daughter, Donna, who helped take care of her mother while the latter was being treated for a heart condition.

That innocent action set up a potentially dangerous situation that was resolved thanks to the patient safety system at Signature Healthcare Brockton Hospital and its “Great Catches” program.

Christine Donna Devine
Christine and Donna Devine

The Great Catches program is among several initiatives funded through a $3.5 million Community Hospital Acceleration, Revitalization, and Transformation (CHART) grant awarded by the Massachusetts Health Policy Commission. The grant is aimed at reducing the 30-day readmission rate of high-risk patients and length of stay for low-acuity emergency department visits, while improving patient safety overall.

The Great Catches portion of the program recognizes employees for reporting near misses—mistakes that happened, but didn’t cause any harm because someone caught them in time.

“The program is designed to help drive up the number of safety reports, so we can keep better track of our composite patient safety numbers,” said Deborah Jean Parsons, Ph.D., the hospital’s CHART program coordinator. “We need to count not only actual safety incidents but also near misses, because both can help us improve our safety systems going forward.”

A possible mix-up over dosages

In Devine’s case, for example, while she was in the hospital her doctors had raised the dose of her regular blood pressure medication from 5 mg per day to 10 mg daily. The blister pack contained 10 mg pills, but they looked similar to the old 5 mg pills and she put them into a bottle marked as containing the lower dosage.  

As a result, when her daughter or the visiting nurses gave Devine two pills daily—in order to meet the doctor’s 10 mg target—they were inadvertently giving her a double dose of the prescription, which could have been dangerous given Devine’s multiple health conditions.

Fortunately, Signature Healthcare had a transitional care pharmacist on staff whose job includes identifying any medication changes or discrepancies and supporting patients in adhering to new treatments.

Erica And Deborah Jean Horizontal
Erica M. Murrell and Deborah Jean Parsons

“I’m part of a program that helps high-need, high-cost patients manage the transition from hospital to home so they can stay healthy and avoid unnecessary readmission,” explained Erica M. Murrell, PharmD.

When a CHART patient goes home from the hospital, Murrell follows up to ensure they have their medications, are taking the right doses and have all the services and information they need. In Devine’s case, Murrell was speaking by phone to Devine’s daughter Donna, who mentioned that her mother was taking two 5 mg blood pressure pills daily. But Murrell, who knew from pharmacy records that Devine had filled a prescription for 10 mg pills, was suspicious.

“By any chance,” Murrell asked, “would your mother have put the 10 mg pills into the 5 mg bottle?” Donna didn’t think so, but when she read off the markings on one of the pills under Murrell’s direction, they discovered the mistake.

Kim Hollon Ceo At Signature Healthcare
Kim Hollon

“Oh, thank goodness you found it,” Donna recalled saying. “This was during the first day or two my mother was home, and things were still pretty confusing. If Erica hadn’t called, we would have continued giving her twice the dose she needed.”

Sharing the lessons with the staff

For Murrell, the incident was a great teaching moment for students at the Brockton Hospital School of Nursing. “I tell them, when you go into a home, look inside every medicine bottle to make sure it contains the right pills. Don’t just assume that what is inside is what’s printed on the label.”

Murrell also dutifully reported the episode to the hospital, and the following week it became one of the Great Catches featured by the hospital leadership in its weekly email to staff.

“The Great Catches program is one of many we have that are aimed at reinforcing our culture of safety,” said Kim Hollon, CEO and president of Signature Healthcare “It sends a strong message that we need to be always on our toes to prevent errors, and use proven safety procedures—like what Erica did—to make up for the fact that even well-intentioned humans make mistakes.”

Signature Healthcare is not alone in using this tool. Other hospitals around the country—ranging from the VA Boston Healthcare System to MedStar Health in the Baltimore, MD/Washington DC area to UCLA Health in Los Angeles—also use some form of recognition for employees who spot near misses. And a recent report in the journal Surgery by physicians at the University of Texas Health Science Center in Houston found that calling attention to “good catches” in the operating room helped boost the effectiveness of pre-surgical checklists.

Barbara Curley Signature Healthcare
Barbara Curley

Two-year improvement effort

But do such efforts actually improve safety? Barbara Curley, M.S., R.N., the hospital’s director of quality, said that since the CHART program began 18 months ago, serious safety events—those that resulted in significant patient harm—are down significantly.

Parsons, the CHART program coordinator, added that the grant also helped the hospital cut the re-admission rate for CHART patients by 30 percent since October 2015.

“Having pharmacists like Erica on our multidisciplinary team has absolutely been instrumental in helping us reach that goal,” said Parsons. “Our CHART patients are not only safer because of the pharmacists’ attention to medications and potential errors, but they’re healthier too.  All in all, it’s a win-win for everyone.” 

For more on "Good Catches" programs from AHRQ, click here.


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