Good Catch Research Articles

What makes a good catch? Effects of variables from individual to regional scales on tropical small-scale fisheries

Small-scale fisheries are vital for millions of people worldwide, but hard to monitor and manage. We investigated the effects of variables related to different spatial scales and theoretical backgrounds, from protected areas (PA) to individual decision-making, on parameters of small-scale fisheries (catch, effort, and catch per unit of effort - CPUE) in the Tapajós and Negro rivers, Amazon. Although both individual- and large-scale variables affected fish landings, the former group was more important. Fish sales, group fishing, and the fishing technique used were the most important variables affecting all parameters. Number of activities performed and time traveled to fishing spot influenced effort and catch. Education level was negatively related with effort. At the large-scale, fishing effort and catch were higher outside PA. Distance to the urban center was positively related with CPUE. Large-scale predictors of fishing yields could help to define broader management goals, while variables at the individual-level may help to identify vulnerable groups to changes in fisheries and to adjust management to minimize conflicts, improving acceptance and compliance.

608 The Impact of a Nurse Morbidity and Mortality Meeting

Abstract Introduction Physicians have long held Morbidity and Mortality (M&M) conferences to discuss complications and deaths. The format for these conferences is to lay out the case, discuss the care performed, and generate discussion on areas of opportunity. Physician M&M usually focuses on teaching and the presenter may not be the caregiver. There is not much literature on the use of this teaching methodology in nursing. Due to the strong culture of safety on the unit, it was determined that creating a Nurse M&M could prove beneficial for discussion of complications, deaths, errors, and good catches as they related to nursing care. Methods Nurse M&M is held monthly for one hour. All personnel involved in the cases are informed ahead of time what will be discussed. They are given the opportunity to present the individual case or give personal testimony as to the situation from their point of view. Each case is presented in the same format. The initial slides cover background, history of present illness, and the origin of the report. Next is the pertinent review from the electronic medical record and discussions had with those involved in the case. The floor is then open for discussion. If there was a variation in practice, the policy that relates to the error is reviewed. Topics for Nurse M&M are gathered through many venues. The hospital uses an online reporting system for electronic submission of adverse events, variations in care, and good catches. The entire multidisciplinary team have all individually reported something they wanted discussed at Nurse M&M. If clarification is needed on a case, the question is directed to the appropriate decision maker and followed up on. Results Nurse M&M is the most highly attended, non-mandatory, meeting held on the unit. The nursing staff was surveyed to determine their perceptions on how the addition of Nurse M&M had effected them. The results were overwhelmingly positive. All nurses surveyed rated the statement, “I feel that Nurse M&M has had a positive outcome on the unit’s collective practice”, as agree or strongly agree. Over time, the notes taken have evolved from just the discussion to action items created off the case. The staff have will now self-report events before they are entered into the online system. Conclusions The nursing staff are highly engaged Nurse M&M. The staff are open to discussing errors in a way that fosters educational growth and critical thinking development. If the case being discussed is because of a personal error, more often than not, the person responsible will discuss why they made the decision they did and facilitate the discussion as to what could have been done differently. The nurses’ commitment to being present, engaged, and open minded are strong signs of the healthy work environment present on the unit. Applicability of Research to Practice The format of a nursing M&M conference is applicable to all units. Patient safety and nurse engagement are the top factors effected by Nurse M&M.

Design of strategic risk mitigation with supply chain risk management and cold chain system approach

Marine fish commodities are perishable food. Many risks that can damage the catch of marine fish includes not stored and carried in low temperature conditions. Therefore, risk mitigation is required to reduce the risks that occur. This research aims to identify, analyze, evaluate and design the strategic risk mitigations with supply chain risk management and cold chain system approach. The supply chain risk management consists of: risk identification, risk analysis, risk evaluation, and risk mitigation in the entire of supply chain. The cold chain system is carried out from upstream to downstream in the activities of fishermen at the Karangantu Fisheries Port, Serang, Banten. The results are identified 16 risk events, 5 priority risk agents, and 5 proactive actions. The proposed strategic risk mitigations are: counseling on how to handle good catch results; adding the Port Operational Section in the field of Fish Demolition Inspection; giving penalties for fishermen who do not handle catching results properly; preparing to unload the results of fishing when the ship is on the dock, and proposing the procurement of fishing aids to the Ministry of Maritime Affairs and Fisheries.

Management strategies for spasmodic stocks: a Canadian Atlantic redfish fishery case study

There exist few recommendations for managing stocks with spasmodic recruitment, despite such stocks being not uncommon. Management procedures (MPs), developed for two species of redfish (Sebastes mentella and Sebastes fasciatus) in eastern Canada, are recommended for setting catch limits during periods of high and low abundance. A well-designed fishery-independent trawl survey is essential to provide advance warning of strong recruitment events and project future recruitment. Under an “inventory management” strategy, a more appropriate aim in spasmodic stocks may be to maximize the number of years with “good catches,” instead of maximizing total catches, as is traditionally considered in management strategy evaluation (MSE). Following a spasmodic recruitment event, an empirical harvest control rule based on larger fish delays the harvest of large cohorts by a few years, targets more commercially valuable fish sizes, and reduces the risk of growth overfishing. Capped MPs produced longer periods of large catches than uncapped MPs. MPs allowed for low harvests during periods of low abundance, thus avoiding unnecessary hardship in the industry. MPs evaluated here could be good candidates for other stocks with similar or less extreme recruitment variability.

Psychological safety and near miss events in radiation oncology.

231 Background: Near miss events, defined as harm averted due to chance, are learning opportunities in radiation oncology. Psychological safety is a feature of a learning environment characterized by interpersonal risk taking. We examine the effects of near miss type and psychological safety on reporting near miss events to an incident learning system. We posit that submission likelihood will differ based on near miss types and psychological safety. Methods: We administered a survey assessing psychological safety to members of a radiation oncology department. We then presented six events for a patient with a pacemaker (PM), which requires cardiac clearance before radiation: process-based (harm averted by systematic PM check); good catch (harm averted by incidental PM check); “could” event (harm averted by chance PM absence); “almost” event (positive PM status, but no sequelae); hit (positive PM status, subsequent arrhythmia); and control (no PM, checked PM status, no sequelae). Subjects ranked each event on submission likelihood (1 = most likely, 7 = least likely), scored events based on submission likelihood by others (1 = least likely, 7 = most likely), and rated event success (1 = failure, 7 = success). ANOVA was used to assess differences in mean rank, submission likelihood, and success ratings. Regression was used to assess the relationship between psychological safety and submission likelihood. Results: The survey yielded 95 out of 127 responses (75%). Mean ranks (p < 0.0001), submission likelihood (p = .042), and success ratings (p < 0.001) differed by near miss type; psychological safety predicted likelihood of submitting the different near miss types (Table 1). 14 respondents (15%) would mind if an incident was submitted about them, while 43 respondents (45%) assume others would mind if an incident was reported related to the others (score > 4). Conclusions: Near miss events proximal to a negative outcome are more likely to be reported, though this effect may be mediated by psychological safety. [Table: see text]

Radiation Oncology Learning Environment and Near Miss Events

Near misses, defined by harm averted due to chance or intervention, are low-cost learning opportunities in radiation oncology. We examine effects of near miss type and learning environment characteristics, such as psychological safety (PS) and time for reflection (TF), on incident reporting and recognition as success versus failure. We posit that perceiving the incident as success is correlated with perceptions of departmental willingness to report (WTR), and that these ratings would differ by near miss type. We also assess the relationship of psychological safety (PS) and time for reflection (TR) with departmental WTR. We administered a survey to members of a radiation oncology department with an incident learning system (ILS). The survey presented six incidents (4 near misses, 1 control, 1 hit) for a patient receiving intravenous contrast: process-based catch with harm averted by systematic creatinine check; good catch with harm averted by staff incidentally checking creatinine; could-have happened harm averted by chance normal creatinine; almost-happened harm with patient’s creatinine elevated and no sequelae; hit event with kidney injury; and control event with normal, checked creatinine and no sequelae. Subjects rated each event for success and departmental WTR on a 1-7 Likert scale, and answered validated PS and TF instruments. ANOVA and ordered logistic regression were used to assess WTR and success rating differences among near miss types, correlations with PS and TR, and real incidents coded as near miss in the department’s ILS database between 2014-2018. The survey yielded 97 of 127 responses (76.4%). Within each near miss type, success rating and WTR were negatively correlated (p<0.0001). There was no difference in WTR nor success ratings among near miss types (p=0.87). Male subjects exhibited a greater trend towards WTR hit events compared to female subjects (p=0.058). TR showed a positive trend with almost-happened events (p=0.085) and was significantly correlated with departmental WTR hits (p=0.007). However, TR showed a negative trend in real ILS reporting of near miss incidents (p=0.077). PS for attending physicians was significantly greater than that for therapists (5.68 vs. 3.56, p = 0.001). TF for therapists (4.31, p=0.034), physicists/dosimetrists (4.18, p=0.007), and nurses/medical assistants (4.33, p=0.048) were significantly less compared to that of physicians (5.81). In free text responses, subjects described the ILS as a platform to report “problems.” Near misses perceived as failures (vs. successes) are more likely to be reported, which corroborates the perception of the ILS as a platform to share problems. Greater time for reflection is correlated with the perception of others’ willingness to report harmful events, though less reflection time may be associated with personal ILS submissions, perhaps due to hierarchical role differences.

QIM19-143: Reducing Risk of IV Chemotherapy Administration Errors Utilizing Pump Integration Technology

Background: The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solve Research Institute is a 356-bed cancer care hospital that is part of The Ohio State University Medical Center. In addition to the inpatient beds, the hospital services 175 ambulatory infusion chairs. Each month, we administer over 6,000 chemotherapy infusions on an IV pump. Smart IV pumps in tandem with hospital information technology infrastructure integrate IV drug administration pump data with the electronic medical record (EMR) and computerized physician order entry to decrease risk of error and increase patient safety. The closed loop system transmits the medication infusion rate and the prescribed dose to the smart pump to deliver the medication. The smart pump in turn transmits the dose and volume delivered to the EMR to accurately capture what the patient received. The ability to wirelessly transmit clinical information from the EMR to automatically program the IV pump with specific data was implemented in March 2018 as part of a system-wide safety initiative to enhance patient safety via the reduction of error during medication administration. Methods: IV pump integration has been in use since March 2018; the organization has robust data on the use of smart pump technology that allowed for comparison of data pre- and postimplementation of pump integration. This includes: total suite usage, count of basic infusions, severe harm averted, total good catches, and event-reporting data. Post-integration, the overall compliance of utilizing pump integration (sending an order from the EMR to the smart IV pump) is also continuously monitored. Results: The implementation of pump interoperability resulted in a safer delivery of infused medications (Figure 1). The use of “basic Infusion” or unprotected infusion function decreased while our use of the appropriate safeguarded pump program increased. The compliance at the medical center increased from about 86% to almost 94%. With increased usage of the pump interoperability, the potential for severe harm as well as human programming errors decreased significantly. Conclusion: The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solve Research Institute is able to deliver infused medications via a smart pump in a safer, more automated system with the implementation of pump integration. We are able to reduce the “human factor” in medication delivery by reducing keystrokes and opportunities for manual programming errors. Pre-integration data cannot be isolated for the cancer hospital only, from our post-implementation data we can infer that our chemotherapy infusions are subsequently safer for our patients.

Wild lobster (Panulirus ornatus) fry fishery in Balete bay, Davao Oriental: Catch trends and implications to fisheries management

The coastal ecosystem of the Philippines is one of the richest and most diverse on earth. Lobsters are one of the commercially exploited species targeted by small-scale fishers for their livelihood and income. This study aims to determine the catch, and catching pattern of the wild lobster fry fishery, quantify the catch per unit effort (CPUE) and identify issues and challenges present in the lobster fry fishery for improved conservation and management. A combination of semi-structured interviews (n = 90), focus group discussion (n = 35) and actual catch monitoring for three months of lobster fry fishers (n = 20) were conducted to elicit information on lobster catch, composition, fishing practices and issues and challenges. Results from the interview and focus groups showed that majority of fishers catch the fries of Panulirus ornatus, Parribacus antarcticus and Panulirus versicolor. They catch most of the lobster fries using bamboo traps and beach seine. The analysis of the CPUE also revealed significant results (P ≤ 0.05) with the good catch having the highest CPUE value (0.30 g) followed by the normal catch (0.16 g) and worst catch of (0.02 g). In terms of weekly field monitoring of the catches of 20 fishers, temporal variation in terms of weeks was highly significant (P = 0.000; R2 = 22). Some management issues mentioned by fishers include effluents from shrimp farming, illegal fishing, chemical residues from mango farms and improper waste disposal. The lack of a management plan, as well as a system to control who has access to the fishing ground of lobster fries, can negatively affect the long-term sustainability of the lobster fry fishery.

STRATEGI PENGEMBANGAN KEAMANAN PRODUK IKAN TUNA (Thunnus albacares) DAN MAHI-MAHI (Coryphaena hippurus) BEKU UNTUK EKSPOR KE BERBAGAI NEGARA DI KAWASAN INDUSTRI MAKASSAR (KIMA)

Food safety is one of the requirements that become non-tariff barriers to enter the export market, mainly on the quality of products that do not meet quality standards set by the importing country. The purpose of this study is to analyze the causes and development of rejection of fishery products in the Makassar Industrial Area (KIMA) and the strategy of increasing the safety of frozen tuna and mahi-mahi products that are suitable for export to various export countries. The study was conducted on August 1 to September 30 2018 in the Makassar industrial area (KIMA). Using the Pareto diagram analysis method, causal analysis and SWOT Analysis. The results showed that during the years 2010-2017, six companies in the Makassar Industrial Area (KIMA) experienced cases of rejection caused by salmonella, filthy and histamine in 25 cases. The results of the priority analysis of fisheries product development strategies were based on the results of the analysis carried out. the best strategies in developing product development are as follows: (1) There is a need to provide comprehensive training on how to handle good catches for fishermen, suppliers by related agencies that are competent in their field; (2) Increased supervision of product quality processed by Quality Control (QC); (3) Companies must be able to review the causes of product rejection so that it does not recur from suppliers, every step of the process until delivery.

Using Good Catches to Promote a Just Culture and Perioperative Patient Safety.

AORN JournalVolume 108, Issue 5 p. 548-552 Column Using Good Catches to Promote a Just Culture and Perioperative Patient Safety Jacqueline J. Monahan MSN, RN, RD, LDN, CNOR, Jacqueline J. Monahan MSN, RN, RD, LDN, CNORSearch for more papers by this author Jacqueline J. Monahan MSN, RN, RD, LDN, CNOR, Jacqueline J. Monahan MSN, RN, RD, LDN, CNORSearch for more papers by this author First published: 30 October 2018 https://doi.org/10.1002/aorn.12394Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume108, Issue5Special Focus Issue: TechnologyNovember 2018Pages 548-552 RelatedInformation

Criteria for a good catch: A conceptual framework to guide sourcing of sustainable salmon fisheries

The identification of sustainably managed fisheries is problematic for marketers and consumers of Pacific salmon food products owing to lack of well-defined and robust criteria that take into account current ecosystem science of salmon. We present the rationale for an alternative conceptual framework for salmon management that supports the development of sustainable sourcing criteria. Our approach contrasts with current large-scale fisheries certification programs such as that of the Marine Stewardship Council (MSC) and general consumer recommendation services such as Monterey Bay Aquarium’s Seafood Watch (SFW) program. Our framework is based on the “place-based” character of salmon populations and recognition of fundamental aspects of salmon ecology, particularly the evolution of population life histories that are locally adapted to freshwater spawning and rearing habitats. We describe how this framework underpins development of science-based sourcing criteria and how it differs in important respects from the industrial approach that historically and currently is the basis for most salmon management. We conclude with a discussion of how the framework and its application may provide a model for redirecting salmon management, in general, towards a more science- and place-based approach and why that is likely to be sustainable in the long term in a way that most contemporary salmon management is not.

OA223] Establishing a unified system for logging radiation incidents in an international healthcare services organisation

Purpose Working in a dynamic, complex and high workload environment can lead to unintended radiation exposures. Unintended does not mean unable to prevent. Establishing a unified incident management system in an international healthcare services organisation facilitates better identification of safety critical steps. A bigger ‘pool of events’ can identify trends in incident types and maximize improvement opportunities across the whole system. Methods There is never a single cause for an incident to happen. The incident management system of the organization, AIMS, is a tool developed to log and learn from any adverse events that concern patients, staff or third-parties under the organization’s care. AIMS is not designed to be an administrative tool to find and penalise individuals, but to support collective learning within the organization network to prevent failures and avoid harm. AIMS is a digital platform accessible to all personnel to log incidents and good catches; incidents which were prevented, due to timely and competent personnel action. It is purposefully a four click process to promote easy and fast logging of events, including process stage, incident type and severity. Once an event is logged, approval of the information provided is required before investigation and analysis of the root causes that lead to the event are initiated. Results AIMS allows the process stage to be logged – that is, the stage in the journey at which the event occurred. In-depth investigation identifies failures in the often-complex healthcare environment, allows detection of risks and developing ways to reduce or eliminate the risk of reoccurrence. Good catches and incidents of moderate and above severity are shared with the group regularly as a learning process. Root cause analysis of events allows scrutiny of the preceding process stages, in order to identify contributory factors leading up to the event and definition of actions. Conclusions To Err is Human. We cannot change the human condition, but we can change the condition under which humans’ work. Incident management is a valuable tool to promote a safety culture and awareness through the involvement of and feedback to staff and managers.

Good Catch Campaign: Improving the Perioperative Culture of Safety.

Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

Good Catch! Using Interdisciplinary Teams and Team Reflexivity to Improve Patient Safety

Interdisciplinary teams play an important role implementing innovations that facilitate the quality and safety of patient care. This article examined the role of reflexivity in team innovation implementation and its association with an objective patient safety outcome, inpatient fall rates (a fall is an unintended downward displacement of a patient’s body to the ground or other object). In this study, we implemented, supported, and evaluated interdisciplinary teams intended to decrease fall risk in 16 small rural hospitals. These hospitals were part of a collaborative that sought to increase knowledge and facilitate reflexivity about fall event reporting and fall risk reduction structures and processes. We assessed team reflexivity at the start and at the end of the 2-year intervention and innovation implementation at the end of the intervention. The 16 hospitals reported objective fall event data and patient days throughout the project, which we used to calculate comparative rates for assisted, unassisted, and injurious falls. The results suggest that teams benefited from the intervention, increasing reflexivity from the start of the project to the end, which was related to innovation implementation and decreases in fall rates. Theoretical and practical applications of the results are discussed.

Big hands result in a good catch

Big hands result in a good catch

A Multidisciplinary Discharge Timeout Checklist Improves Patient Education and Captures Discharge Process Errors.

To design and implement a discharge timeout checklist, and to assess its effects on patients' understanding as well as the potential impact on preventable medical errors surrounding hospital discharges to home. Based on the structure successfully used for surgical procedures and using the Model for Improvement framework, we designed a discharge checklist to review and assess patients' understanding of discharge medications, catheters, home care plans, follow-up, symptoms, and who to call with problems after discharge. In parallel, we developed a process of integrating the checklist into the discharge process after routine discharge procedures were completed. We used the checklists to assess patients' level of understanding and need for additional education as well as changes in discharge documentation; we also noted whether good catches of significant errors in the discharge process occurred. Over 6 months of study, 190 discharge timeouts out of 429 eligible discharges were completed. Additional education was provided in 53 of 190 discharge timeouts (27.8%), with 62% of this education being related to medications. Twenty-one (11.1%) discharge timeouts resulted in at least one change to the discharge documentation or a good catch. A multidisciplinary discharge timeout directly involving the patient can be effective in targeting additional areas for patient education and in potentially reducing preventable adverse events.

10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System.

Background:In 2014, Children’s National Health System’s executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.Methods:Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.Results:Children’s National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as “other” decreased from a baseline of 6% to 2%.Conclusions:Children’s National Health System’s focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

Lessons Learned From the VA Radiotherapy Incident Reporting and Analysis System (RIRAS)

The intranet Web-based RIRAS was developed and deployed in the Veterans Health Administration (VHA) System to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences at its 39 radiation oncology practices nationwide. 286 reports were electronically submitted to the RIRAS between 5/11/2014 and 1/02/2017. Each reported event included information on the incident chronology, general information specific to the treatment modality, site and intent and free text narrative. All reports were carefully analyzed by a radiation oncology subject matter expert (SME) and assigned to one of the eight discrete radiation oncology process steps. Steps relate to where the event was discovered and/or occurred. As part of the analysis, error type, medical and dosimetric severity, interventions and potential causes were recorded for each report. Patient safety work products (PSWP) created for these reports listed corrective, preventive and learning actions. For learning purposes, the anonymized version of each PSWP is publicly available on the RIRAS website, which enhances the safety culture. We completed causal analysis and developed corrective action plans for 100% of the reported incidents. Out of a total of 286 reports, 35% were actual events of which 3% met the criteria of VHA misadministration classification but with a low medical severity. 61% were good catches/ near misses, 4% were unsafe conditions. 32% of the reported events occurred in the treatment planning phase, 28% in the treatment delivery phase and 7% in the imaging for treatment verification phase. 31% of the events were discovered by the radiation physicist, 25% by the radiation therapist and 19% by the attending radiation oncologist. 32% of the events were related to organizational management issues like non-existent or inadequate policy and procedures. 31% were related to procedural issues such as distractions / loss of attention and poor documentation. 24% were human behavior related to poor judgement and lack of vigilance. 9% were based on technical issues such as lack of IT / biomedical attention. 36 reports were due to documentation errors, 11 based on previous RT treatment not taken into account for retreatment and 12 due to inconsistent patient setup instructions. Based on the analyses of reported incidents, we were able to make individualized recommendations for radiotherapy process improvement to enhance patient safety at each reporting facility. While RIRAS utilization is a marker of a positive safety culture within VHA, it is important to have a concrete plan for following up, learning and documenting process improvements from the reported events. We found that the ability to learn is significantly enhanced when the reporter is self-identified and there is an ability to request additional information on the event.

Implementing An Integrated In-Situ Coaching, Observational Audit, and Story-Telling Intervention to Support Safe Surgery

This article describes an intervention that combined in-situ coaching, observational audits and story-telling to educate theatre teams at University College London Hospitals about the Five steps to safer surgery (NPSA 2010). Our philosophy was to educate theatre teams about 'what goes right' (good catches, exemplary leadership etc) as well as 'what could be improved'. Results showed improvements on 'behavioural reliability' metrics, a 68% increase in near miss reporting and a reduction in surgical harm incidents.

Meaningful use and good catches: More appropriate metrics for checklist effectiveness

The benefit of utilizing surgical safety checklists has been recently questioned. We evaluated our checklist performance after implementing a program that includes checklist-related good catches. Multifaceted interventions aimed at the preincision checklist and 5 prospective audits were conducted from 2011-2015. We documented adherence to the checklist (verbalization of each checkpoint), fidelity (meaningful performance of each checkpoint), and good catches (events with the potential to cause the patient harm but that were prevented from occurring). Good catches were divided into quality improvement-based categories (processes, medication, safety, communication, and equipment). A total of 1,346 checklist performances were observed (range, 144-373/yr). Adherence to the preincision checklist improved from 30% to 95% (P<.001), while adherence to the preinduction and debriefing checklists decreased (71% to 56%, P=.002) and remained unchanged (76%), respectively. Preincision fidelity decreased from 86% to 76% (P=.012). Good catches were identified during 16% of preincision checklist performances; process issues were most common (32%) followed by issues of medication administration (30%) and safety (22%). Implementation of a systematic checklist program resulted in significant and sustainable improvement in performance. Meaningful use and associated good catches may be more appropriate metric than actual patient harm for measuring checklist effectiveness. Although not previously described, checklist-related good catches represent an unknown benefit of checklists.