American College of Physicians: Internal Medicine — Doctors for Adults ®


Good catch!

Reporting near misses prevents bigger mistakes later

From the December ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Janet Colwell

Sumit Bhagra, MD, an endocrinologist at Mayo Clinic Health System in Albert Lea, Minn., sensed something was wrong as he prepared to perform a needle biopsy on a patient with thyroid nodules. The patient's right side had been prepped but something told Dr. Bhagra to double check the patient's chart, a precaution that prevented a potentially harmful mistake.

“The nurse was taking shortcuts by asking the patient what side they thought they were here for and, even though the chart clearly mentioned it was one side, the wrong site was prepped,” said Dr. Bhagra. “Had we not looked at the chart before doing the procedure, I might have taken the path of least resistance and done the biopsy as planned.”

Illustration by Barry Moshinski, with Thinkstock i...

Illustration by Barry Moshinski, with Thinkstock images.

Dr. Bhagra's quick thinking prompted his colleagues to nominate him for the Minnesota Hospital Association's annual Good Catch for Patient Safety award, which recognizes hospital staff for reporting “near miss” incidents that were caught in time to prevent harm to patients. Mayo also took concrete action based on Dr. Bhagra's report by retraining the prep nurse and reviewing with staff the process and documentation required before procedures.

Mayo's Albert Lea clinic has implemented many changes to improve safety over the past decade based on near miss reports made by employees via its online Patient Safety Zone reporting system. Every time an employee submits a report, a memo is automatically sent to the appropriate unit manager for immediate follow-up. A safety leadership team, which includes the hospital's medical director, reviews all reports weekly to identify trends and recommend changes to systems or workflow.

Other hospitals around the country are reaping the benefits of similar near miss reporting programs—and facing the challenge of convincing employees they won't be punished for reporting. It's definitely worth the effort, said Tonia Lauer, quality administrative officer at the Mayo Clinic in Albert Lea.

“It gives us 1,200 eyes and ears throughout the hospital,” said Ms. Lauer. “It gives us that frontline focus so we catch the things you don't even see unless you're working at the bedside.”

Spotting patterns, identifying risks

While all hospitals accredited under The Joint Commission are expected to report and investigate sentinel events, defined as unexpected occurrences involving death or serious injury, near misses often go unreported.

“Instead of waiting for adverse events to happen, we should collect data on near misses and use a forward looking approach,” said Peter J. Fabri, MD, professor of surgery and of industrial engineering at University of South Florida (USF) Health in Tampa, who spearheaded USF's near miss reporting program five years ago. “You can look at near misses to identify places where you want to invest resources to create systems to prevent adverse events.”

Unlike in sentinel event reporting, a root cause analysis of every near miss is not necessary, just documentation of the basic circumstances surrounding the occurrence, he said. The goal is to spot trends. One near miss report isn't very meaningful but a cluster of reports dealing with a similar type of error can point to areas where adverse events are likely to happen.

As a case in point, a group of near miss reports several years ago involving attempted cholecystectomy in patients who had already had their gall bladders removed prompted the Pennsylvania Patient Safety Reporting System (PA-PSRS) to put out an advisory to all hospitals detailing the risks and suggesting ways to avoid similar problems. In each of the three reports reviewed, the diagnosis relied on ultrasound alone, and the patient was elderly and uncertain about whether their gall bladder had been removed previously.

“They started the procedure and in the middle found out that the patient didn't have a gall bladder,” said William Marella, program director for the patient safety reporting program at ECRI Institute, a federally designated Patient Safety Organization, and director of PA-PSRS. “No one ever writes up that sort of thing in the literature because it's embarrassing, but we were able to see a pattern.”

The goal of collecting near miss reports is to understand why mistakes happen as opposed to assigning blame, said Linda Connell, RN, director of the Aviation Safety Reporting System and the Patient Safety Reporting System (PSRS), a prototype developed in collaboration with the National Aeronautics and Space Administration (NASA) in partnership with the Department of Veterans Affairs (VA) medical system from 2000-2009 (more information is online).

“Is there a link that could have been part of the chain of events that, if changed, could prevent further incidents?” said Ms. Connell. “People may have felt they did something wrong but in actuality it's probably the system that's not helping them do the right thing.”

Changes made as a result of near miss reports can be simple but meaningful, noted Ms. Lauer at Mayo. For example, one near miss report alerted administrators to a functional problem with a unit's automatic doors, which were closing so quickly that it was impossible for an elderly patient with a walker to get through. “We got someone from engineering up there right away to change the timing on the door,” she said.

Blame-free reporting

Like Mayo's Albert Lea clinic, the University of Connecticut Health Center's John Dempsey Hospital in Farmington, Conn., encourages employees to report by including high-level medical executives on safety teams, recognizing employees for participation, and highlighting the changes made as a result of reports.

“We try to create a blame-free environment,” said Scott Allen, MD, medical director for quality programs at John Dempsey. Any employee can submit an adverse event or near miss report through the hospital's online Patient Safety Net reporting system, which typically receives anywhere from four to 12 reports per day. Every report triggers e-mail alerts to the safety committee members and the appropriate unit manager. In addition, the safety committee meets three times a week with front line staff to discuss how to correct problems.

When submitting a report, employees can choose to remain anonymous, but they must sign their report to be eligible for the hospital's Good Catch award, which is given to several employees each month. A three-member committee, consisting of Dr. Allen, Ann Marie Capo, RN, associate vice president for quality programs, and Pamela Marshalkowski, director of regulatory compliance, reviews nominations for the award and selects winners.

Members of the safety committee go directly to the winner's unit to present the award, which consists of a catcher's mitt lapel pin, an award certificate (copied to their personnel file) and recognition in the staff newsletter.

“It's something to be proud of,” said Ms. Marshalkowski, who chairs the safety committee. “It's become a contest on the units to see who can catch the most things.”

Convincing physicians

Setting up a reporting program is a first step but the real challenge is getting people to use it, said Dr. Fabri. Many employees simply don't trust that their reports won't be used against them, even when they are promised anonymity.

“We created a system, came up with a standard, computerized method of reporting and it only took an average of 30 seconds to report a near miss. It was totally anonymous and we trained every single employee in the institution how to do it,” said Dr. Fabri. “It still didn't work. We get about two reports a month and we propose that there are probably about 100 [near misses] a week.”

While hospitals such as Mayo and John Dempsey have made strides in creating a culture of trust, they acknowledge that physicians are still hesitant to admit a mistake even if it didn't result in harm to a patient.

“Most doctors still perceive that things will be counted against them or go on their record,” said Mr. Marella. However, that perception can be overcome by consistently demonstrating how the reports are being used in positive ways, he said.

“Often people miss the opportunity to make visible the positive changes that happen as a result of reporting,” he said. “Doctors are very data- and evidence-driven. If they see changes being made in areas that matter to them, that is the most compelling argument to get them to report things.”

For Dr. Bhagra, it's far better to report a near miss incident than to stay quiet and risk being involved in a potentially avoidable adverse event down the road.

Clinicians need to acknowledge that they are “human and prone to error,” said Dr. Bhagra. “Someone speaking up is simply a double check to prevent errors, complications and potential liability in the future. Even though ego and pride might be hurt, the goal should be a culture of speaking up without fear.”

Janet Colwell is a freelance writer in Miami.



ACP New York Chapter's Near Miss Registry

The New York Chapter of the American College of Physicians (NYACP), in partnership with the New York State Department of Health, has been collecting data on near misses since 2007 via its online Near Miss Registry. This voluntary, confidential reporting system collects anonymous reports on near misses from health care professionals with the goal of identifying vulnerabilities and strengths in the health care system. The program defines a near miss as an event that might have resulted in harm to a patient, but was discovered and corrected before it reached the patient.

At first, reporting for the survey was limited to residents trained in internal medicine (IM) in hospitals in New York State. Initially, more than 1,500 residents in New York received patient safety training. In 2010, the program was expanded beyond IM residents to all residents, medical students, and physicians in all specialties—and then to all health care workers. The program's educational team continues to reach out to health care workers so they can learn about medical errors, as well as how to access the anonymous survey.

So far, data analysis has shown the most common near miss events involve medication (such as prescribing the wrong dose, or prescribing a medication to which a patient is allergic), followed by communication issues. Since nearly 19% of the drug administration events in 2007-2009 involved anticoagulation therapy, the NYACP has taken steps to increase awareness of appropriate anticoagulation therapy and dosing. The chapter offered a one-hour training Webinar, conducted pilot testing on the effectiveness of training, and is currently highlighting "best practices" related to anticoagulation therapy in its newsletter.

Data analysis has also statistically confirmed that well-developed safety systems in hospitals are effective barriers to error, Chapter representatives said, adding that. hospitals which do not incorporate many safety systems tend to rely on humans as barriers to error, with less effective results. Evidence is mounting that more hospitals in New York State are using a variety of safety systems, including Computerized Physician Order Entry, Electronic Health Records and Bar Coding, they added.

Health care workers in New York State can submit a near miss report by going to the registry website and typing "near miss" in the login box.

Discussions are underway to expand the New York Near Miss Registry beyond New York State, through national ACP, Chapter representatives said.

ACP Hospitalist previously wrote about the Near Miss Registry in April 2008.



Good catches spur action

The following are a few examples of near miss reports by hospital employees that led to safety improvements:

  • A report received by the Pennsylvania Patient Safety Reporting System (PA-PSRS) said that a patient received an unintentional shock (but was uninjured) during a bedside defibrillator check. An investigation revealed that the nursing assistant who was performing the checks didn't realize that the pads were attached to the patient during the check. PA-PSRS sent out an advisory to all member hospitals suggesting that only qualified clinical staff perform defibrillator checks and that appropriate training be provided.
  • At the University of Connecticut Health Center's John Dempsey Hospital, a near miss report alerted the safety committee that a latex-allergic patient had received a latex Foley catheter. To prevent future incidents, staff began using color codes to separate latex from non-latex catheters.
  • At a VA medical facility, a technician doing a routine inspection found that some infusor pumps used in the operating room could deliver an incorrect dose of anesthetic if an incorrect syringe size was used in certain pumps. As a result, VA anesthesiology departments were advised to stock the correct brand of disposable syringe and ensure that the pump's syringe selector switch identifies the brand prior to use.


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