Celebrating a Great Catch for Patient Safety at CFMH

Kaitlin Belcher, RN was recently nominated for a Great Catch award by Kristin Brandenberger, Pharmacist at CFMH. Kaitlin identified and questioned a medication order that had been entered and verified in the electronic medical record. Recognizing that the ordered dose appeared significantly higher than expected, she appropriately escalated her concern for further review. Upon reassessment it was determined the order was incorrect. The incorrect order was discontinued and the appropriate order entered.

This intervention prevented the administration of the incorrect dose of medication and the potential for patient harm. In addition, the event revealed a gap within Epic that did not appropriately flag the unusually high dose for review. The finding prompted a system-wide optimization to strengthen medication safety safeguards and reduce the risk of similar events in the future.

This Great Catch highlights the importance of vigilance, speaking up for safety, interdisciplinary collaboration, and leveraging opportunities to improve system processes.