title: Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "good catch" awards.
abstract: BACKGROUND
  Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them.
  
  
  METHODS
  A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time.
  
  
  RESULTS
  Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail.
  
  
  CONCLUSIONS
  A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA. kherzer@jhmi.edu
authors.forename: Kurt R
authors.initials: KR
authors.lastname: Herzer
authors.forename: Meredith
authors.initials: M
authors.lastname: Mirrer
authors.forename: Yanjun
authors.initials: Y
authors.lastname: Xie
authors.forename: Jochen
authors.initials: J
authors.lastname: Steppan
authors.forename: Matthew
authors.initials: M
authors.lastname: Li
authors.forename: Clinton
authors.initials: C
authors.lastname: Jung
authors.forename: Renee
authors.initials: R
authors.lastname: Cover
authors.forename: Peter A
authors.initials: PA
authors.lastname: Doyle
authors.forename: Lynette J
authors.initials: LJ
authors.lastname: Mark
mesh_terms: D026683:Advisory Committees / Q000458:organization & administration*; D001363:Awards and Prizes; D004282:Documentation / Q000379:methods*; D006784:Hospitals, Teaching / Q000592:standards*; D006801:Humans; D007857:Leadership; D008396:Maryland; D019300:Medical Errors / Q000517:prevention & control; D009873:Operating Rooms / Q000458:organization & administration; D015279:Organizational Culture; D061214:Patient Safety / Q000592:standards*; D058996:Quality Improvement / Q000458:organization & administration*; D017751:Safety Management / Q000458:organization & administration