Good Catch in Action: Preventing Medication Errors and Improving Patient Care
By Dole VA Office of Communication Services
“Good catch!” It’s something you hear quite often at baseball diamonds and football fields. But, did you know the term is also used in the healthcare industry?
The Good Catch Award recognizes proactive efforts by individuals to prevent an incident or even harm through corrective action or timely intervention.
During a routine diabetes management visit, Dr. Elizabeth “Lizzie” Cook, pharmacist, identified that a Veteran's prescription had been incorrectly renewed at twice the recommended maximum dose for a two-week period. After confirming the Veteran's previous regimen, she instructed the patient not to administer the incorrect dose and updated the prescription.
The event resulted in a system-wide change to the drug’s file in VA’s medical record system by removing the default dosing frequency, thus reducing the risk of future prescribing errors.
Dr. Cook’s attention to detail and intervention prevented a potentially harmful medication error and drove a system-wide improvement that enhances medication safety for future patients.