“Learning depends critically on the less visible social processes of inquiry, investigation and improvement that unfold around incidents.”

Would you agree?

Carl Macrae presented the above viewpoint in his British Medical Journal article titled The problem with incident reporting. He argues that we “collect too much and do too little”—that we must refocus our efforts on learning and sharing to ensure that incidents are transformed into action.

Here at BCPSLS, we agree that the learning component of our provincial safety and learning system is vital to making our healthcare system safer for patients.

And we’re not alone.

Efforts to learn from incidents and make positive changes are ongoing throughout the province. And sometimes these changes begin with a single incident that was reported thoroughly and followed up in a timely and thoughtful fashion.

To recognize the important work being done by those who report and follow up on incidents, two regional health authorities in BC have implemented recognition programs that acknowledge staff, share learnings, and have lasting impacts on safety culture.

Good Catch Award

At Providence Health Care (PHC), staff are being recognized for reporting good catches.

And we’re not talking about the results of their latest fishing trip.

In patient safety lingo, a good catch, or near miss, is a problem that was caught and prevented from reaching a patient. Good catches are different from no harm events, which are events that reach the patient but don’t cause any harm.

According to Sarah Carriere, Leader, Patient Safety for PHC, good catches are “free lessons”. They provide an opportunity for us to intervene and prevent the next patient in a similar situation from being put at risk or harmed.

Each month, Sarah reviews near misses reported into PSLS, including resulting learnings and actions taken. If a good catch has triggered process or system-level change, or has the potential to do so, Sarah acknowledges the reporter with a Good Catch Award.

“The Good Catch Award doesn’t take much time or budget, but it has a big impact,” says Sarah. “It shows that reporting near misses effects change that can spread to other departments. It’s also great for reporters to hear that their reports make a difference.”

The Good Catch Award is presented to the reporter during a surprise visit by Sarah to the unit. She presents the reporter with a certificate, a gift card, and a letter outlining the positive changes that resulted from the reporter’s good catch. The reporter and resulting improvements are then acknowledged in the PHC News.

Some managers get involved and make it a team-building experience for staff with cake and a celebration.

“It’s a great opportunity for me to introduce myself to the units,” adds Sarah. “And for nurses, I remind them that they are meeting their professional standards of care by using PSLS.”

The Good Catch Award also recognizes staff who follow up on incidents—PSLS handlers—whose thorough investigation of an incident led to improvements in patient safety.

And we aren’t the only ones who are impressed by this program: the Good Catch Award was given a special mention by Accreditation Canada surveyors during their final presentation at PHC’s last accreditation survey!

Most Helpful PSLS

Vancouver Coastal Health (VCH) has been formally recognizing PSLS handlers since 2015 with their Most Helpful PSLS challenge, which now includes reporters, as well.

The contest was initiated by Terri Aitken, PSLS Coordinator for VCH. Terri developed the idea while attending the BC Patient Safety & Quality Council’s Quality Academy, a program that teaches participants how to lead quality and safety initiatives within their own organizations.

Each month, Terri begins the challenge by reviewing all the patient safety incidents reported in PSLS during a randomly selected week, as well as reports that were assigned final approval status—meaning investigation was completed—that week.

In order to be eligible to win, the reported patient safety incident must include:

• detailed description of the event without the use of names or identifiers
• accurate assessment of harm, if applicable
• contributing factors
• assigned handler to follow up
• safety ideas

The criteria for records assigned final approval status are even more rigorous.

To make the cut, events must be reviewed and advanced within recommended time ranges (e.g. maximum of 5 days between initial report and first review, and no more than 30 days to completed review) and the follow-up must include:

• medical specialty of the attending or admitting physician or most responsible physician, if applicable
• contributing factors
• notes about review activities
• summary of findings
• actions taken
• feedback to reporter

To select the winners, Terri chooses randomly from the reports that meet all the criteria: one reporter and one handler from each of VCH’s four Communities of Care: Vancouver Acute, Vancouver Community, Richmond, and Coastal.

Each winner receives a certificate and a gift card.

“The program lets people know that their reports and follow-up mean something,” says Terri. “It helps close the loop.”

But the grand prize is reserved for those who really go the extra mile.

Each year, Terri and a small review committee from each Community of Care select one handler from each area to be awarded the Most Helpful PSLS. In addition to meeting the criteria above, the Most Helpful PSLS must include a complete, post-review description of the incident as well as a thoughtful and well-documented investigation, including learnings. Bonus marks are awarded for including actions taken or learnings shared with interdisciplinary teams.

It may sound gruelling, but the payoff is worth it.

The Most Helpful PSLS winners from each VCH Community of Care, and one ultimate Most Helpful PSLS for all of VCH, are sponsored to attend the BC Patient Safety & Quality Council’s popular Quality Forum.

“The highlight for me was having the patient voice present and engaged at the Quality Forum,” says Avee Khela, this year’s Most Helpful PSLS winner for Vancouver Community. “It really showed me how the work we do or don’t do impacts the experiences and outcomes for patients and their families in life changing ways.”

Learning and sharing

While it’s true that incident reporting may have some inherent challenges, it provides innumerable opportunities for learning and making improvements to the safety of patient care.

“PSLS has made a big difference for me at work,” says Kara Thompson, Clinical Resource Nurse at Richmond Hospital and two-time winner of the Most Helpful PSLS award for Richmond Community of Care. “I’m so motivated to stop issues from happening over and over. I encourage others to see PSLS not as work, but an opportunity to make a change and make the patient’s journey at the hospital safer. It’s not just a task—there is a lot of learning that comes out of the PSLS process.”

Whether it’s a good catch, a properly reported event, or a thoroughly investigated incident, all of us can help keep the focus on learning and sharing.

Congrats to all the winners and everyone who plays a role in making healthcare safer for patients in BC!

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