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Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety

This featured profile is available on the Agency for Healthcare Research and Quality’s Health
Care Innovations Exchange Web site. The University of Texas M.D. Anderson Cancer Center
implemented a multifaceted initiative, known as the Good Catch Program. The program was
designed to increase the reporting of potential errors related to medication, equipment, and
patient care. Key elements of the program include (1) a change in use of terminology from
negative to positive terms and phrases (e.g., from “close call” or “near miss” to “good catch”);
(2) friendly, team-based competition to promote reporting; (3) development of an end-of-shift
safety report; (4) executive leadership-sponsored rounds and incentives; and (5) a
multidisciplinary workgroup to promote reporting. The program increased the reporting of
potential errors dramatically, by 1,468 percent, in the 6-month pilot phase of the program and
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spurred the development of action plans designed to address the common causes of potential
errors.

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