Date of Award

5-2016

Document Type

Capstone

Degree Name

Master of Public Health (MPH)

Department

Public Health

First Advisor

Judy Tupper

Keywords

long term care reporting, WISER, patient safety, Maine nursing homes, Good Catch

Abstract

Rationale and processes for reporting near misses and evidence-based tools were collected by a literature search, seminal works by Sidney Dekker and James Reason, and websites for the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI), and the Centers for Medicare and Medicaid Services (CMS). Tools, information, and strategies found in this research were evaluated for implementation in Maine nursing homes. The tools provide a communication vehicle for nursing home staff to safely report to management near misses, or mistakes that do not harm residents. To emphasize a positive approach, the project replaces the term “near miss” with “good catch.” The final contract for the WISER Phase II project was delayed and therefore the guided discussion as planned for the project could not be held. Instead, two tools were developed to present to WISER participants once Phase II is underway. Good Catch tools were created for use in skilled nursing facilities. Along with WISER project participants, additional audiences for this work include long term care patient safety officers interested in internal reporting of near misses to improve their systems and culture change.