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Focusing on near misses can bring major improvements

When it comes to patient safety, residents have a big role in detecting close calls and suggesting solutions

From the September ACP Observer, copyright © 2005 by the American College of Physicians.

By Yasmine Iqbal

Over the course of her year as an intern, Melissa Stevens, MD, said she learned to think about near-miss mistakes and medical errors in a whole new way.

For Dr. Stevens, now a third-year internal medicine resident at Emory University Hospital in Atlanta, that change came after attending Emory's resident conferences on patient safety. When the sessions, she said, threatened to devolve into "old-fashioned blame discussions," conference moderator, associate residency director Nathan O. Spell, ACP Member, would ask whether they could imagine themselves causing the error or contributing to the near miss under discussion.

He'd then encourage them to think about each incident as an instance where multiple processes were failing to protect patients, not as one person's error-in-the-making.

"I realized then that this was a bigger issue than just correcting one isolated event," Dr. Stevens said. "We realized we were all going to keep making mistakes, so we needed to focus on creating a system where mistakes wouldn't reach the patients."

Residency programs nationwide are trying to teach those same lessons to housestaff, especially because residents are so well positioned to detect "near misses"—potential medical mistakes that are caught before patients are affected. (Also see "Near misses and the impact of work hour rules.")

"Residents are at the sharp end of patient safety," noted Mary B. Duke, FACP, an associate program director at the University of Kentucky in Lexington, Ky., and Governor-elect for the ACP Kentucky Chapter. "They see what's working and what isn't." Many times, residents just deal with near misses and move on. But now they're being encouraged to report potential (as well as actual) errors and design ways to change the underlying processes that allow near misses to happen.

Realizing the value of near misses

Detecting, reporting, and studying adverse events have been a key part of the patient safety movement, which came under new scrutiny with the Institute of Medicine's 1999 "To Err is Human" report.

That report galvanized many states into developing mandatory error reporting systems. It also spurred this summer's passage of the Patient Safety and Quality Improvement Act of 2005, which creates a national system for voluntary, confidential reporting of medical errors—a measure the College has advocated for on Capitol Hill for years.

Experts say, however, that actual adverse events are only the tip of the iceberg. Studying near misses, which occur much more frequently, can provide a more comprehensive snapshot of a hospital's weaknesses—and are much easier to report.

"There's less emotion involved," said Dr. Duke, "and less risk to the reporter, because no harm befell the patient." Still, residents, and physicians in general, often tend to overlook the value of reporting and studying near misses.

"They figure if nothing really happened to the patient, they don't need to report the incident," said Daniel D. Buff, FACP, associate program director at St. John's Episcopal Hospital in Far Rockaway, N.Y. "Physicians need to understand that near misses indicate problems in the system that might someday lead to serious harm."

At the same time, residents might be reluctant to report and discuss near misses because they feel powerless to effect change, said Michael Couturie, MD, a second-year resident at Temple University Hospital in Philadelphia.

"We don't see ourselves as power players," Dr. Couturie said. "Hospitals need to develop a culture where residents become stakeholders in how the system runs—and residents need to understand that part of being a professional is thinking about systems solutions."

Reporting at the point of care

At Temple, its three-month DISCLOSE pilot project has given physicians the tools to report near misses and errors at the point of care.

To allow participating physicians to note incidents quickly and easily, the DISCLOSE team—consisting of Emmanuel S. King, ACP Member; Darilyn V. Moyer, ACP Member, internal medicine program director; and David J. Shulkin, FACP, who was then Temple's chief medical officer and patient safety officer—created a pocket-sized form that lists different types of near misses or errors, with space to describe the incident. (The acronym stands for the main classes of errors: Drugs, Iatrogenic causes, System issues, Communications, Labs and tests, Oversights, Staff and Equipment.)

In the project's pilot phase, forms were distributed to 39 attending physicians who together submitted a total of 122 reports. Assistant professor of medicine Bizath Taqui, MD, was initially skeptical about the project, but was soon won over.

"The form was simple and user friendly, and you could fill it out any way you wanted," she said. "Just having it in my pocket made me more aware of incidents." She was soon using the forms almost every day to note problems resulting from night-float handoffs and other events that she'd typically just write off.

According to Dr. King, an assistant professor of medicine at Temple and one of the project's creators, DISCLOSE reporting revealed that some patients were being discharged before their electrocardiograms (EKGs) were analyzed—a near miss because, in some cases, those results would have changed the way the patient was managed.

An investigation revealed the underlying cause: Technicians were leaving the EKGs in a large bin by the nurses' station where they were often overlooked, allowing physicians to forget to follow up on the EKGs they had ordered. Now, technicians place the EKGs along with the patients' charts in wall bins outside patients' rooms, letting physicians know the EKG was taken and prompting them to examine, interpret and document the results.

"We need to emphasize," Dr. Moyer said, "that being able to recognize near misses, acknowledging mistakes and taking steps to fix them is as critical a part of residents' education as passing the Boards."

Creating an open environment

This month, Temple's DISCLOSE team is launching another venue to allow residents to scrutinize near misses: a new conference where second- and third-year residents will discuss near misses and other patient safety issues.

With this new effort, Temple joins a growing list of hospitals that are initiating multidisciplinary conferences where residents, faculty, nursing staff and other key players can discuss such events in a non-punitive environment.

So, too, at Emory. Like many other residents, Dr. Stevens' first experiences with patient safety and quality improvement discussions were morbidity and mortality (M&M) conferences where, she said, "physicians were berated for making mistakes."

But in the monthly M&M conferences he moderates at Emory, Dr. Spell said he works hard to keep the environment more open. Instead of assigning blame, residents present cases, go through a root cause analysis of each event, brainstorm practical solutions—and then submit their recommendations to the hospital's chief quality officer.

To keep the conference productive, Dr. Spell lists the ground rules at the beginning of each meeting: no finger pointing, focus on the process of care, keep solutions practical and obey the moderator.

"People tend to get defensive and shift blame, but they need to understand that we are all in this together and there is a way to fix these problems," he said. He noted that residents have slowly become more proactive about finding and discussing incidents because they know their concerns will be taken seriously.

At the Hospital of the University of Pennsylvania (HUP) in Philadelphia, faculty preceptors with expertise in quality improvement help choose cases for monthly resident patient safety meetings. According to patient safety officer Jennifer S. Myers, ACP Member, this helps steer the cases and conversation "toward systems issues that require discussion and change, and away from blame and complaints."

Several resident recommendations originating in HUP's safety meetings have resulted in concrete changes. One example: the creation of a standardized process for accepting outside hospital transfer patients' medical information.

During one of the safety reports, it was discovered that inter-hospital transfers were an area where near misses kept occurring because of poor and untimely communication with physicians outside the hospital. A resident spearheaded the redesign and standardization of the documentation that HUP uses to collect this information—and made it available on the hospital's electronic information system.

Now, Dr. Myers explained, "residents and faculty will have full access to a transfer patient's outside hospital records well before the time of actual transfer." This will help eliminate the often-hurried review of records that takes place when sick patients arrive on the floor with their stack of records at the bedside. She added, "It will also help our physicians triage transfer patients to the appropriate level of care in the hospital."

It's one more example of how fostering an open discussion of near misses can improve patient care. "We're finally changing the way we think about errors," said University of Kentucky's Dr. Duke. "We used to think that if we just worked harder, we wouldn't make errors. Now we're realizing that errors are inevitable, and we need to build systems that keep patients from being harmed by them."

Yasmine Iqbal is a Philadelphia-area freelance writer specializing in health care.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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Near misses and the impact of work hour rules

Across the country, near misses—which are potential medical errors prevented before patients are harmed—are being scrutinized to reveal underlying areas of hospitals' vulnerability.

And in New York state, near misses are also being scrutinized in the context of resident work hour rules. Internists from the state ACP chapters and the state special-interest group for the Association of Program Directors in Internal Medicine (APDIM) have begun studying whether resident duty hour restrictions have enhanced patient safety.

"We knew the restrictions were supposed to result in less fatigued residents and safer care," said Ethan D. Fried, FACP, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York. "But we were also realizing that the increased number of patient handoffs might lead to more errors."

To track those effects, the New York ACP/APDIM group decided to create a Web-based survey to identify, classify and study near misses, believing that they could gather data more quickly and get a more comprehensive picture than if they focused solely on adverse events. (In New York, Dr. Fried noted, actual errors have their own state-mandated reporting system.)

The survey, which is online, is designed to collect specific facts about each near miss, including what happened, when it happened and the role of the persons involved. Although the survey is targeted to residents, others can report as well. Five New York teaching hospitals, including St. John's Episcopal Hospital in Far Rockaway, are participating in the pilot phase, which began in January.

To examine the effects that duty hour regulations might have, the survey also asks how many hours the person was working when the event occurred and whether the hospital has a night float coverage program. After completing the survey, participants can print out a certificate they can use to fulfill Accreditation Council for Graduate Medical Education competency requirements for systems-based practice, practice-based learning and quality improvement.

To encourage residents to report incidents, the developers tried to ensure that the reports would be anonymous and untraceable by the data analysis team. But not all reporters are completely anonymous. St. John's Episcopal has modified the reporting process, said Daniel D. Buff, FACP, the hospital's associate program director. Instead of relying on residents reporting incidents on their own, they report the incidents to him. He then investigates each report and enters the data into the system.

"The hospital wanted to make sure the information would be accurate and fair, and assuring the administration that I would be the only one submitting reports was the only way I could convince them to get involved," he said. The process seems to work; so far, St. John's has submitted more than half of the 40 near-miss reports logged in on the Web site.

To boost the number of resident reports, Dr. Fried said the group is looking into ways to promote the survey's use and increase survey access at the point of care. Now that the survey's pilot phase is complete, the survey will be retooled and rolled out to more hospitals, and may eventually be made available nationwide.

Already, however, some trends have emerged, including a host of coverage-related errors. Eighty percent of the near misses reported, for example, have been due to faulty signouts. Of these, 60% occurred as a failure to communicate an adverse drug event or the inappropriate use of a drug that was subsequently reordered, while 40% involved a failure to ask about or follow up on a pending diagnostic test, which caused a delay in treatment.

And reports have led to specific changes. At St. John's Episcopal, for instance, residents took steps to minimize coverage errors by creating signoff forms that prompted physicians for key information, such as what specific lab tests had been ordered. According to Dr. Buff, requiring physicians to fill in the form fields—instead of just jotting down freeform notes—seems to keep information from falling through the cracks.

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