What if the most powerful opportunities to prevent harm in healthcare are the ones that never reach the patient? Near misses—events caught before causing patient harm—often go unnoticed, yet they offer some of the clearest insight into system vulnerabilities and patient risk.

Safety- minded organizations view near misses not as failures, but as opportunities for learning, improvement, and resilience. In this presentation, I share insights gained from examining near-miss reporting through a Safety and Quality lens at United Hospital Hastings–Regina Campus and River Falls Area Hospital, where I partnered with leaders to design a sustainable initiative, a Good Catch program, that aims to promote psychological safety, increase event reporting, and strengthen staff engagement through visible follow-through on concerns.

This presentation highlights the value of near misses, reviews the change management process used to develop a recognition-based Good Catch program, and shares key takeaways for future change initiatives focused on sustainability, shared leadership, and harm prevention.

Advisor: Kristin Morris