I was on one of the great Patient Safety Management Network drop-ins the other week, where they were sharing the learning from a safety observation session. The Session had been in a busy A&E department and at one point the observer flagged that a patient hadn’t been given a name tag for their wrist. The observer stepped in, identified the harm and it was rectified. I asked in the meeting chat if the organisation in question had flagged this as a near miss? "No, I don’t think so" was the response – "there are just too many near misses, and we are just too busy to report every one." Many folk on the call agreed.

I was surprised to hear this. Having spent nearly 20 years married to a chemical engineer and spending a lot of my free time with engineers from across industry, I know that this behaviour would be totally unacceptable across the organisational cultures they work in, and potentially a reportable/disciplinary issue. Interestingly, their ingrained behaviours and cultures are such that it doesn’t usually get to that stage as everyone just knows what the right thing to do is and there are systems and cultures to make it easy.

However, not the NHS it seems. As my husband said when we discussed this later, "this is free learning, and there are hundreds of firms across the country willing to show you tools and techniques to make reporting quick and easy".

A colleague of mine, who was recently clinical, mentioned how ‘busy’ and ‘longwinded’ some reporting forms are... having to log into a computer (if one is available) while so busy: "I used to do mine at the end of a shift, not getting home till after 10 at night despite finishing at 20:15".

Going back to the PSMN drop-in, what was really interesting was a nurse from the USA at the meeting was one of the few who agreed that not reporting near misses was really poor safety culture. She talked about how they are an aspiring high reliability organisation and how "we love near misses – we call them great catches". 

What can you do today to start changing your safety culture? How can you make it easy for all staff to do the right thing? A culture that doesn’t blame with easy, quick processes to follow, and support for staff to do just that. 

Go and make a great catch and prevent the next patient/member of staff suffering the same harm. As we know, a great catch missed today could become something far worse tomorrow.

Do you have a 'good catch' reporting system? Share your experiences and questions in our Community thread or comment below You'll need to register for free first. .

Related reading:

• Near-Miss and Good-Catch Reporting
• Promote a culture of safety with good catch reports
• Using good catches to increase worker ownership of safety
• 5 Examples of good catches in healthcare and how to implement a near miss campaign

Challenge:

In healthcare, are we investigating the wrong incidents?