Great Catch, Team Member! Always double check

Great catch, team member! Each month we highlight and recognize an educational opportunity where a potential problem was caught or solved before it was a safety issue.

Great catch, Aubrie Rafferty! Aubrie is a pharmacist at Mission Hospital.

What was achieved?  

A patient’s discharge summary showed the patient was discharged on March 9, 2017, but the actual discharge was not until March 14, 2017. The discharge disposition section was not completed at the time of the pharmacist’s review. A consult for Lovenox education was placed, but it was almost not done by pharmacy since it was thought that the patient had been discharged to a facility. Not all patients being discharged receive this consult due to the large volume of patients on anticoagulants and limited pharmacy resources. Those transferring to a facility usually do not receive personal instruction. Upon further exploration, the pharmacist found that the patient was being discharged to a home, not a facility; so Lovenox education was completed.

What was the Great Catch?

The patient may have easily been discharged home without instruction on how to take this anticoagulant medication safely and serious bleeding or clotting consequences may have occurred. Since the documentation was incomplete, the pharmacist did a thorough review of the record, discovered the need and addressed it before the patient was discharged.

What made this a Great Catch?

This event shows a complex issue, attention to detail, a high index of suspicion and thorough follow up.

How can I report my Great Catch or other events?

Any team member can use RL Solutions to report any safety event. Access RL Solutions either by clicking the icon from your Mission Health desktop or from Citrix Applications. Once in RL Solutions, Pick the report that most fits your near miss or event. For more information, visit our MOD page.

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