Hospitals becoming more open about near-misses
Hospitals becoming more open about near-misses
Hospitals share more despite potential problems
Most quality professionals are well-versed on the importance of learning from "near misses" and medical mistakes made at their organizations. But a growing number are now learning from errors made at other hospitals as well. "There is more openness than there used to be, although it's certainly not universal," says Eric J. Thomas, MD, MPH, principal investigator of the University of Texas Center of Excellence for Patient Safety Research and Practice in Houston.
The University of Texas Close Call Reporting System (UTCCRS) is a voluntary, anonymous tool currently being implemented at 10 participating hospitals. The program gathers information about close calls — situations that could have resulted in an accident, injury, or illness, but did not due to chance or a timely intervention. Information from the close call reports will be used to develop targeted interventions for the participating hospitals and identify best practices in quality improvement.
"We aggregate the data and work with our hospitals to make sense of the information we are getting," says Debora Simmons, RN, MSN, CCRN, CCNS, associate director for the Institute for Healthcare Excellence at the University of Texas M. D. Anderson Cancer Center in Houston. Most hospitals do root cause analyses, but they lack an understanding of the cognitive and human factors that go into these errors, says Simmons. "So it is very difficult for them to make meaning out of some of these reports, because they are looking at it from a less in-depth type of understanding. Humans are not going to perform perfectly all the time — it's not going to happen. We need to start designing the workplace to prevent errors with design changes."
One hospital reported a close call that involved a health care provider finding a concentrated electrolyte in a heparin bin. "The vial looked exactly like the heparin that should have been in the bin. The practitioner opened the drawer and got the medication, but it was misfiled in the machine," says Simmons.
The hospital was alerted immediately and discovered that the same medication was misfiled in several other areas. "Eventually someone would have picked up the wrong drug and made that error," says Simmons. Close call reporting allows the hospitals to anticipate and mitigate these errors, she says.
After the hospital reported that concentrated electrolytes were misfiled in more than one medication dispenser, an e-mail alert was sent to all participating hospitals. Two other facilities found the identical error in their machines. This data was forwarded to the FDA, which released an alert on a national level, warning health care facilities of the potential mix up and misfiling.
When it comes to automated medication dispensers, the group's data show that the human response is to either implicitly trust the computer and think it's infallible, or distrust it completely, says Simmons. "In health care, that information will be very important as we go toward computerized order entry as well as dispensing," she says. "We tend to think of computers as a remedy for safety. In reality, they are adding more complexity to tasks, and we do not understand how this will affect safety."
The data also have picked up basic process problems, such as frequently missing medication doses, which is a hazard to patient care. "Soon, we can start aggregating the analysis of these events, put them in clusters, and perform a more in-depth analysis," says Simmons. The idea behind the analysis is to determine what, if any, commonalities exist in timing, location, or type of drug. When common issues are found, this usually points to something within the current system that might be responsive to a systemic preventive intervention, says Simmons. "We also use a simple classification system and severity scale to rate issues," she says. "In the future, when we can share data, we will be able to compare nationally with other groups. This provides early chances to intervene."
The goal is to give hospitals an "early warning" and sometimes identify a potential fix to stop future errors from occurring, and share these alerts with other participating hospitals. "We do a lot of informal sharing and conference calling," says Simmons. "We are in constant contact with our liaisons at each hospital regarding their close calls, along with the many issues that can arise at different hospitals."
However, not all the participating hospitals have been successful in getting staff to report close calls. Of the ones that do, successful strategies include having a champion for the program, having executives remind staff to report close calls during rounds, and holding a competition to see which unit reports the most close calls. "That has been wildly successful," says Simmons. "People have really enjoyed competing with each other in reporting safety events."
Indiana group teams up
"We are beginning to learn and appreciate that patient safety is a system-related issue. It's somewhat of a struggle, but we are making good progress from the past, when you would point a finger at an individual, to acknowledging that we created the environment that allowed that situation to occur," says Jon Rahman, MD, chief medical officer at St. Vincent Health, part of the Ascension Health System, which has 16 facilities throughout central Indiana.
As a result, organizations are being more open about their adverse outcomes in an effort to identify safer practices. "We are much more willing to share our unplanned outcomes so that others can learn from them," Rahman says.
The city of Indianapolis has a patient safety coalition that meets regularly, and participating hospitals share information about adverse events. "This is a highly competitive market, but we have all agreed that this is a community expectation," says Rahman. "Everybody in the city is involved in this, and we all take it very seriously."
The city's hospitals also developed a uniform agreement for what abbreviations will not be used, and survey results on patient safety are shared. Currently, the hospitals are working to standardize how surgical marking is done for right side surgery, since personnel may work in more than one facility. "Those are the kinds of things that we've been able to come together on," says Rahman. "We all have the patient's best interest at heart."
[For more information, contact:
Jon Rahman, MD, System VP & Chief Medical Officer, St. Vincent Health, 8425 Harcourt Rd., Indianapolis, IN 46260. Telephone: (317) 338-7057. Fax: (317) 338-4715. E-mail: [email protected].
Debora Simmons, RN, MSN, CCRN, CCNS, Associate Director, Institute for Healthcare Excellence, The University of Texas M D Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. Telephone: (713) 792-9524. E-mail: [email protected].]
Most quality professionals are well-versed on the importance of learning from "near misses" and medical mistakes made at their organizations. But a growing number are now learning from errors made at other hospitals as well.Subscribe Now for Access
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