46 Cultivating a safety symphony through good catch and great save awards in ambulatory care center

Background Fear of blame leads to underreporting of incidents.¹ Celebrating good catches and great saves can create a more positive and supportive safety culture. Good Catch is defined as a near-miss event that did not reach the patient because of the thoughtful actions of an employee,² whereas Great Save is an event that reached a patient with minimal to no harm but required immediate action to contain the situation by the actions of an employee. The Ambulatory Care Center (ACC), which employs around 413 nurses, is also facing underreporting challenges, echoing a prevalent issue in healthcare settings. Appreciation of managing potentially harmful events and reporting incidents can help reverse this mindset. By the end of 2023, we aimed to empower at least 10% of ACC nurses to report potential errors and success stories following the implementation of the Good Catch/Great Save awarding program.

Methods Starting in January 2023, we utilized PDSA (Plan-Do-Study-Act) cycles in identifying barriers and overcoming them by promoting a No Blame, No Shame culture.³ Educating staff on the importance of reporting incidents, emphasizing ACC’s commitment to a blame-free culture empowered staff to report without fear. In June 2023 we celebrated Good Catches and Great Saves in ACC with gifts and certificates.

Results A 12.5% increase in reporting demonstrates that ACC is improving towards building a culture where staff feel empowered to report incidents without fear of blame. In 2023, 15 staff received Great Save awards (figure 1) and 37 Good Catch were reported (figure 2). Notably, 62% of reported ‘Good Catches’ were medication incidents whereas all reported ‘Great Save’ showcased nurse’s quick response in saving patient‘s life.

Conclusion The rewarding strategy played a pivotal role in empowering staff nurses to report proactively, reinforcing a positive culture, and ensuring a safer and more productive work environment.

References

1. Oweidat I, Al-Mugheed K, Alsenany SA, Abdelaliem SMF, Alzoubi MM. Awareness of reporting practices and barriers to incident reporting among nurses. BMC Nursing 2023;22. https://doi.org/10.1186/s12912-023-01376-9

2. Lozito M, Whiteman K, Swanson-Biearman B, Barkhymer M, Stephens K. Good catch campaign: improving the perioperative culture of safety. AORN Journal 2018;107:705–14. https://doi.org/10.1002/aorn.12148

3. Kinney M, Day L, Palestra F, Biswas A, Jackson D, Roos N, et al. Overcoming blame culture: key strategies to catalyse maternal and perinatal death surveillance and response. BJOG: An International Journal of Obstetrics & Gynaecology 2021;129:839–44. https://doi.org/10.1111/1471-0528.16989

Ethical Approval/IRB Statement This quality improvement project focused on internal process improvement without experimental interventions or external data collection therefore it was exempted from ethical approval or Institutional Review Board review and approved by the CEO of the Ambulatory Care Center, Doha, Qatar.

Disclosures and Acknowledgments Nothing to disclose and no conflict of interest.