The Power of Good Catches: Strengthening Patient Safety through Event Reporting
Special Insights
Sponsored by the FSHP Medication Safety Clinical Forum
Contributing Authors:
Jaimi Luke, PharmD, BCPS
Tim Carbone, PharmD, MBA, BCGP
Michelle Lamarque, PharmD, BCPS
Robyn Yarsley, PharmD, BCPS
Shivana Syne, PharmD, MHA, BCPS
Healthcare systems utilize event reporting systems to identify both preventable and non-preventable gaps in processes and behaviors that could negatively impact patient safety.
These issues are traditionally categorized as either active failures, associated with human error and individual mistakes, or latent failures, which result from system-based faults and error-producing conditions that passively create risks to patient safety.¹
Reducing latent factors is a major focus in event reporting as human presence will always have the potential of influencing poor outcomes, as addressed in the Institute of Medicine landmark report ‘To Err is Human’.²
However, identifying and reporting both types of failures is crucial in enhancing safety and outcomes, regardless of whether they result in direct patient harm.
By recognizing and reporting “good catches” or near misses, these events are able to be discovered and intercepted before they reach the patient.³
These represent critical opportunities in identifying vulnerabilities within the system and in promoting a proactive approach to safety, organizations can address risks early on and ideally prevent recurrence of errors.
Despite these risks, many medication safety events can be prevented through good catches and reporting the near miss incident.
Examples of good catches surrounding medication safety include identifying an incorrect medication through barcode scanning with BCMA, immediate clarification of ambiguous or confusing orders and prescriptions, and intercepting dosing errors at pharmacist verification before it reaches a patient.⁸,⁹
Although these events may not always result in harm, their impact is still significant and when reported, good catches expose system gaps and drive meaningful process improvements with the overall goal to reduce the chance of recurrence.
Frequent reporting is preferred over temporary workaround measures as these are not true solutions and do not eliminate the underlying vulnerability, potentially introducing new risks through these alternate pathways.
Pharmacists may encounter a wide range of medication errors and risky behaviors in daily practice and are uniquely positioned to promote a supportive environment that encourages reporting of good catches.
Psychological safety is essential for encouraging disclosure of these events and is achieved by creating an environment where good catches are consistently reported and rewarded.
A ‘Just Culture’ supports open communication by focusing on objective learning and system improvement rather than placing blame.¹⁰
When staff feel safe raising concerns and trust that their reports will be taken seriously, organizations see increased reporting, collaboration, and overall safer patient care.
By valuing good catches and supporting open reporting, healthcare systems transform vigilance into patient safety improvements.
As previously published in the FLORxIDA Times 18th Issue last summer, the Medication Safety survey conducted by the FSHP Medication Safety Clinical Forum KPI Workgroup identified key performance indicators (KPIs) used for improving medication safety, with pharmacy leaders across nearly twenty different organizations answering questions surrounding medication safety issues, including good catch reporting.
Of the 23 respondents, 18 of them (78%) report tracking good catches with 11 reporters provided details by both total number of events reported (8/11) and specific good catch reporting (3/11).
Tracking of these events was often manually tracked via Microsoft Excel or Word and overall noted to be inconsistent across institutions. Due to the small sample size and variability in medication safety practices across Florida institutions, there is further opportunity to standardize KPIs surrounding good catch reporting.
Pharmacists may encounter a wide range of medication errors and risky behaviors in daily practice and are uniquely positioned to promote a supportive environment that encourages reporting of good catches.
Reporting our good catches as recommended by ISMP Best Practices 2026-2027 increases awareness of the potential path to patient harm, with each report serving as a data point that can drive meaningful changes to the system, prevent future errors, and ultimately enhance patient safety.¹¹
References:
- Dietrich, E., & Gums, J. G. (2018). Incident-to Billing for Pharmacists. Journal of managed care & specialty pharmacy, 24(12), 1273–1276.
- REGULATION OF PROFESSIONS AND OCCUPATIONS, 465 PHARMACY U.S.C. § 1865 (2025).https://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0465/Sections/0465.1865.html
- REGULATION OF PROFESSIONS AND OCCUPATIONS, 465 PHARMACY U.S.C. § 0125 (2025).https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0465/Sections/0465.0125.html
- American Society of Health-System Pharmacists. (2024). Advancing healthcare: Key steps to implementing pharmacist provider status. ASHP.
- Clements, J. N., Emmons, R. P., Anderson, S. L., Chow, M., Coon, S., Irwin, A. N., Mukherjee, S. M., Sease, J. M., Thrasher, K., & Witek, S. R. (2021). Current and future state of quality metrics and performance indicators in comprehensive medication management for ambulatory care pharmacy practice. Journal of the American College of Clinical Pharmacy, 4(4), 390–405.
- American Society of Health-System Pharmacists. (2020). Practice Advancement Initiative 2030: Recommendations for advancing pharmacy practice through the next decade. ASHP.
| Medication Error | Any preventable event creating inappropriate medication use or patient harm while the medication is in control of the healthcare professional, patient, or consumer
Medication Error Result Categories:
|
| Adverse Drug Event (ADE) | Any harm experienced by a patient as a result of exposure to a medication, possibly due to a medication error
ADE Categories:
|
| Adverse Drug Reaction (ADR) | Type of adverse drug event due to a harmful and unintended response to a drug that is often unavoidable and occurs at normal dosing ranges for prophylaxis or therapeutic dosing |
| Good Catch | A medication error or unsafe condition that occurred but is identified and corrected prior to reaching the patient |
Contemporary View of Medication–Related Harm. A New Paradigm. NCC MERP and Medication Errors. www.nccmerp.org
This article was submitted for the FLORxIDA Times | July 2026, Issue 22.
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