Good Catch Awards at Iowa City VA
From left: Ann Satterly, R.N., post-transplant coordinator, Carol Winetroub, LISW, renal transplant social worker, and Dawn Oxley, acting facility director.
Our facility’s program was started in March 2013. As of the date of this publication, 88 close calls have been reported and acted upon by staff members.
Reporting close calls is extremely important to VA’s patient safety efforts. Close calls provide an exceptional opportunity for learning and afford the chance to develop preventive strategies and actions before a patient is harmed. That’s because they have been shown to be as much as 300 times more common than actual adverse events.
Below are examples of recent “Good Catch” awards. We are proud of those members of our staff who earned them and helped to promote our facility’s patient safety efforts.
From left: Melisa Cernic-Kates, R.N., behavioral health nurse, Erik Stalhandske, then acting facility director, and Wes Klema, VA police officer.
Melisa Cernic-Kates, R.N., Nine West Behavioral Medicine, and Wes Klema, Iowa City VA police officer.
Nine West received a call via the hospital operator from a Veteran – who lived out of state – with a gun and thoughts of committing suicide. The staff was unable to access the Veteran’s medical records to identify his location. Officer Klema stepped in to assist, tracked the patient’s location through his phone number, and called local authorities to have a health and welfare check completed.
Ms. Cernic-Kates kept the Veteran on the phone for 45 minutes, using her therapeutic communication skills, which gave local authorities time to arrive at his home.
A “Good Catch” award recognized these two staff members for identifying the danger the Veteran was in and taking action to ensure his safety.
Carol Winetroub, renal transplant social worker, and Ann Satterly, transplant coordinator
These two staff members had been working with a patient from out of state since September 2013 for a possible kidney transplant. The process involves the patient meeting certain goals, with follow-up reviews every 3-4 weeks.
Ms. Winetroub and Ms. Satterly found notes stating that the patient had taken a turn for the worse, having become completely dependent upon oxygen and placed in a nursing home.
But they also found that some of the notes did not seem to go along with others − painting a different picture of the patient’s condition.
Ms. Winetroub asked the other facility for the patient’s full Social Security number, instead of only the last four. It was found that two VA patients had the same name and same last four Social Security numbers, which had led to the confusing chart entries.
The “Good Catch” was awarded for the work of these two staff members. Had the mix-up not been discovered, the Veteran would have been denied a kidney transplant based on the poor condition of another Veteran with the same name and last four Social Security numbers.
