Pharmacists everywhere understand the importance of reporting medication incidents – especially when patient harm occurs – but many remain less convinced about the importance of reporting near-miss events, or ‘good catches.’
Good catches occur regularly in pharmacies when medication errors or potential safety issues are caught before they reach the patient. Most believe that because no harm actually occurred, reporting the issue might not be worth their time.
However, reporting good catches in addition to medication incidents is critical.
In many pharmacies, good catches occur more frequently than medication incidents. If they’re not reported, we’re missing a huge opportunity to learn from trends in the data that identify similar problems within the system that can be improved to eliminate the risk of future harm. Taking a few minutes to report your good catches is truly one of the most effective ways to support system changes that will improve patient safety everywhere — and help save you time and money in the long run.
For example, consider this scenario:
Drug shortages are a common problem impacting pharmacies. A shortage of the drug Altace HCT 10mg Ramipril/12.5mg Hydrochlorothiazide meant pharmacists need to change the drug to perhaps two separate drugs e.g., Ramipril 10 mg and 12.5mg Hydrochlorothiazide.
In one pharmacy, the change was mistakenly prepared as two tablets of AltaceHCT 5mg Ramipril/12.5mg Hydrochlorothiazide, but the pharmacist caught the error before it was dispensed to the patient. The pharmacist who caught the error assumed it was an isolated incident not worthy of reporting, however, because the drug shortages were occurring on a national level, similar scenarios were playing out in pharmacies across the country.
By reporting the factors that contributed to the good catch – in this case drug shortages – we’re able to collect and analyze data on both a provincial and national scale and share the findings with stakeholders and regulatory authorities who have the power to implement change.
One pharmacy reporting a good catch appears as one tree. Many pharmacies reporting the same issue makes a forest. The bigger the forest, the easier it is to see the scale of the problem and how it impacts the trees.
Reporting good catches can also make big impacts on a smaller scale and help you identify areas within your specific pharmacy that can be improved. For example, if medications are frequently confused because they look alike, could it be resolved by stocking different brands for look-alike, sound-alike drugs so they look different. Would marking them help better differentiate them? By making small changes in your unique location, operational efficiencies are gained and reduction of duplication of work is quickly realized.
When Should Good Catches be Reported?
Remember, the goal of reporting good catches is not to add more administrative burden to your day. The goal is to help identify the root cause of problems so solutions can be proactively implemented. The more data we have, the better we can understand when and where things are going wrong.
To encourage employees to report good catches (and medication incidents), common barriers to reporting must be removed. These typically include: lack of reporting culture, absence of a reporting system, management behaviour, and fear of consequences.
It’s important to establish a just culture in your pharmacy, where reporting is encouraged. Incident and near-miss reports should always be viewed as learning opportunities, not an opportunity to shame or blame individuals.
While it might not be feasible to report every good catch that occurs in your pharmacy, there are certain scenarios that should always be reported. These include:
1. The good catch would have caused harm had it reached the patient.
e.g., 5 units of insulin vs 50 units.
2. The problem is a recurring issue in the pharmacy.
e.g., lookalike/soundalike drugs are dispensed in error.
3. It provides a learning opportunity for the pharmacy practice.
e.g., the incident leading to the good catch was a result of skipped steps in pharmacy processes.
4. Reporting the issue aligns with guidance set by your provincial regulator.
e.g., near-miss event reporting is expected in Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia
Tips for Getting Started
Start small – commit to reporting one or two good catches per week to get in the habit.
Set aside 10 to 15 minutes per day – dedicate a small amount of time each day to complete reports.
Share the responsibility – reporting doesn’t need to fall solely on the shoulders of one individual. The Pharmapod reporting platform allows for roles-based access, so certain employees can access and input information as required.
Increase communication – ask employees if they have any good catches they’d like to share. Take the time to discuss what happened, and share how future incidents can be prevented.
Get more advice on simplifying medication incident and near-miss reporting here.
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