In 2020, Kettering Health adopted the Zero Harm strategy to reduce the occurrence of harm events, such as falls with injury, medication errors, hospital-acquired infections, etc. Zero Harm depends on the concept of Just Culture. Just Culture helps create an environment where it is safe to report events and near misses. To encourage reporting, Kettering Health has a Great Catch program designed to celebrate and learn from events where harm was caught before it reached the patient. Only when events are reported can we develop actions to prevent them.
Considering the Vanderbilt case, in which a nurse was criminally prosecuted, we understand concern in reporting events. We are also concerned about this and feel that medical errors must be evaluated under a Just Culture framework—and not in the legal arena.
When there is no intent to harm someone, the behavior would fall under either human error or at-risk behavior. The response to the former is to console; the response to latter is to coach. Our investigation processes, including Root Cause Analyses, focus on finding system issues that can be fixed rather than being a punitive process. Hospitals that have the best and safest care must have a true Culture of Safety where transparency rules and everyone reports errors and near misses so the bar can be raised. We ask you do the same, and we will support you 100% under the framework of Just Culture.
Great Catches
A great catch is when someone proactively prevents harm from reaching the patient. Kettering Health uses safety events reported through Great Catches and Midas to make positive changes and improvements across the system. Great catches are celebrated each day at the respective campus Daily Safety Briefing. Please share your great catches with your leader so your commitment to patient safety can be celebrated.
June 2022 Great Catches
- Thank you, Kim Wheeler, for your great catch. Kim caught a chemotherapy that was prepared in the wrong type of bag and without filter tubing. Kim returned the bag to Pharmacy and had it corrected and remade. Thanks to Kim’s attention to detail, she prevented potential patient harm.
- Thank you, Kayla Harton, for your critical thinking. Kayla had a patient with an order for a foley. Kayla did not think a foley was appropriate for the patient and reached out to the physician. It was discovered that the foley was pre-checked in an order set. This was taken to the CAUTI team where the order set was corrected. Thank you, Kayla.
Medication safety: Heparin Weight-based Infusions
Heparin weight-based infusions are titratable infusions that are initiated by using a patient’s weight and then titrated every 6 hours based on Anti-Xa lab levels. To ensure the accuracy of following the protocol dosing, it is highly encouraged to use the Initiation and the Dose Adjustment calculators for Heparin infusions. The Heparin protocols/order sets are for DVT/PE/AFIB or ACS/Acute MI/ Unstable Angina. Based on your feedback, the protocols have been updated with specific administration instructions on the MAR that clearly specify not to exceed the max dose and to use the Heparin MAR calculators.