AJR: CPOE at root of many near misses
The majority of ‘near misses’ in radiology are repeated errors that carry severe risks for patients, and yet nearly half are detected by simple good fortune, without barriers to prevent the problems from actually occurring, according to a single institution study published in the May issue of the American Journal of Roentgenology.
Near misses, also called good catches and close calls, represent errors by a hospital or provider that are detected and remedied just before affecting or harming a patient. At Memorial Sloan-Kettering Cancer Center in New York City, for example, near misses accounted for one-third of the hospital’s 17,668 reported events over a two-year period, according to Raymond H. Thornton, MD, an interventional radiologist at Memorial Sloan-Kettering, and colleagues.
“Such events, though rich with opportunities for free learning about system vulnerabilities, often receive little attention because they are not associated with bad outcomes,” Thornton and co-authors wrote. “Actual adverse events and active patient complaints tend to consume the bulk of quality, safety and risk management resources in healthcare, limiting the time available for analysis of things that only nearly went wrong.”
Thornton and colleagues developed a system for evaluating and scoring the criticality of near misses occurring in the hospital’s department of radiology. The scale scored close calls from 1 (lowest risk) to 180 (highest risk) based on a variety of factors, including: the worst potential outcome of the error, the frequency with which the near miss had already occurred, whether the error had barriers that helped prevent it from occurring and the quality of those barriers. Thornton and colleagues arrived at each score by multiplying together the scores of all of an individual error’s criteria.
Out of 62 near misses that occurred in the radiology department between 2007 and 2009, 65 percent could have resulted in the most severe potential outcome, including death or regulatory breeches. Fifteen percent of all close calls earned maximal hazard scores, incorporating all risk criteria, of 180.
The most common errors originated from computerized provider order entry (CPOE), which accounted for 32 percent of all close calls. Only two of these errors originated in the department of radiology.
If missed, the most common events that would have occurred included the wrong procedure (14 cases), wrong patient (13 cases) and wrong-side procedures (11 cases). In one case, a pregnant woman was nearly sent for a CT scan.
Most near misses had occurred previously, with only 6 percent of errors having never occurred before. Yet, in nearly half of these close calls, no clear barrier could be identified that would have definitely caught the error before it affected the patient.
The authors considered strong barriers to be present in just more than one-quarter of close calls. Similarly, 40 percent of errors were caught by good fortune, rather than checks set up in the department’s workflow.
Thornton and co-authors labeled CPOE as a “critical vulnerability,” with the recent increase in Sloan-Kettering’s CPOE errors attributable chiefly to the human-technology interface.
Care and service coordination errors, referring to mistakes that occurred in the hand-off or follow-up of patients between providers (i.e., from radiologist to cardiologist), accounted for 19 percent of near misses. Incorrect patient identification was the third most common error, tallying 16 percent of close calls.
“Most event types in our series were repetitive, having occurred three or more times. Novel events were uncommon, accounting for only 6 percent of cases. This is consistent with the teaching that nearly all important adverse events have precursors,” Thornton and colleagues wrote.
“The ability to stratify such events on the basis of local strengths and vulnerabilities could assist with appropriate identification of and resource allocation for in-depth analysis and action on the highest risk near-miss occurrences,” the authors continued.
“We think that this method, although designed for use in a radiology environment, is transferable to other medical domains.”
Near misses, also called good catches and close calls, represent errors by a hospital or provider that are detected and remedied just before affecting or harming a patient. At Memorial Sloan-Kettering Cancer Center in New York City, for example, near misses accounted for one-third of the hospital’s 17,668 reported events over a two-year period, according to Raymond H. Thornton, MD, an interventional radiologist at Memorial Sloan-Kettering, and colleagues.
“Such events, though rich with opportunities for free learning about system vulnerabilities, often receive little attention because they are not associated with bad outcomes,” Thornton and co-authors wrote. “Actual adverse events and active patient complaints tend to consume the bulk of quality, safety and risk management resources in healthcare, limiting the time available for analysis of things that only nearly went wrong.”
Thornton and colleagues developed a system for evaluating and scoring the criticality of near misses occurring in the hospital’s department of radiology. The scale scored close calls from 1 (lowest risk) to 180 (highest risk) based on a variety of factors, including: the worst potential outcome of the error, the frequency with which the near miss had already occurred, whether the error had barriers that helped prevent it from occurring and the quality of those barriers. Thornton and colleagues arrived at each score by multiplying together the scores of all of an individual error’s criteria.
Out of 62 near misses that occurred in the radiology department between 2007 and 2009, 65 percent could have resulted in the most severe potential outcome, including death or regulatory breeches. Fifteen percent of all close calls earned maximal hazard scores, incorporating all risk criteria, of 180.
The most common errors originated from computerized provider order entry (CPOE), which accounted for 32 percent of all close calls. Only two of these errors originated in the department of radiology.
If missed, the most common events that would have occurred included the wrong procedure (14 cases), wrong patient (13 cases) and wrong-side procedures (11 cases). In one case, a pregnant woman was nearly sent for a CT scan.
Most near misses had occurred previously, with only 6 percent of errors having never occurred before. Yet, in nearly half of these close calls, no clear barrier could be identified that would have definitely caught the error before it affected the patient.
The authors considered strong barriers to be present in just more than one-quarter of close calls. Similarly, 40 percent of errors were caught by good fortune, rather than checks set up in the department’s workflow.
Thornton and co-authors labeled CPOE as a “critical vulnerability,” with the recent increase in Sloan-Kettering’s CPOE errors attributable chiefly to the human-technology interface.
Care and service coordination errors, referring to mistakes that occurred in the hand-off or follow-up of patients between providers (i.e., from radiologist to cardiologist), accounted for 19 percent of near misses. Incorrect patient identification was the third most common error, tallying 16 percent of close calls.
“Most event types in our series were repetitive, having occurred three or more times. Novel events were uncommon, accounting for only 6 percent of cases. This is consistent with the teaching that nearly all important adverse events have precursors,” Thornton and colleagues wrote.
“The ability to stratify such events on the basis of local strengths and vulnerabilities could assist with appropriate identification of and resource allocation for in-depth analysis and action on the highest risk near-miss occurrences,” the authors continued.
“We think that this method, although designed for use in a radiology environment, is transferable to other medical domains.”