Near Misses

The medical literature pertaining to patient safety is voluminous, especially since the publication of the 1999 Institute of Medicine (IOM) report estimating that between 44,000 and 98,000 Americans die from medical errors each year.1 When focusing on hospitalists and the matter of near misses, however, where the outcome of the error has been intercepted before harm can occur, the volume of published information is far more limited.2

“There are few good data about the role that hospitalists play in preventing adverse events,” says Saul Weingart, MD, PhD, vice president for patient safety at the Dana-Farber Cancer Institute, Boston, “so most accounts are anecdotal. My own sense is that hospital medicine plays a critical role in preventing and mitigating errors in the acute care setting.”

One study, conducted by two hospitalists in a 200-bed academic hospital and published in 2003 in the Journal of General Internal Medicine, distinguished near misses from adverse events.3 The investigators set out to determine the frequency, types, and consequences of errors that can be detected by hospitalists during routine clinical care, and to compare the types of errors first discovered by hospitalists to those discovered by other providers.

Sarwat Chaudhry, MD, a former hospitalist who is now a health services researcher and assistant professor of medicine at the Yale School of Medicine in New Haven, Conn., was the lead investigator in that study. “Oftentimes the errors that are ‘sexier’ and more exciting for people to talk about are the adverse events,” she says. “But I think what are perhaps more common and more informative are the near misses.”

Definitions

For purposes of Chaudhry, et al.’s study, “adverse events” were defined as adverse outcomes that resulted from errors.3 Errors that did not result in patient harm, but could have, were categorized as near misses. The umbrella definition of error fit that which was used in the IOM report; that is, “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”1 Cases in which a bad outcome occurred (such as death or disability) without a preventable cause were not considered errors and, therefore, were not included in the data.

A more practical understanding of a near miss is apparent in the following illustration: “If pharmacy came to me and said, ‘Oh, Dr. Chaudhry, one of the physicians on your team wrote for drug X but the patient is also on drug Y and that’s a known contraindication so we don’t think this should be administered, do you agree?’ I’d say, ‘Yes, I agree.’ So the drug was never given, but it was a near miss for the way it was written if it hadn’t been picked up on.”

In fact there are two kinds of near misses. “One is where the error is intercepted by [a] pharmacy or somebody else before harm is done,” says Dr. Weingart. “The other kind is where the error reaches the patient—for instance, where he or she receives the antibiotic to which they are allergic—but no reaction takes place.”

An important element in the study was that both types of errors were identified during the course of routine, clinical care by Dr. Chaudhry and her colleague, Kolawole Olofinboba, MD. Errors first detected by other healthcare workers were also recorded. Of the 528 patients included in the study, 10.4% experienced at least one error: 6.2% a near miss and 4.2% an adverse event. Interestingly, most of the errors first detected by house staff, nurses, and laboratory technicians were adverse events, whereas most of the errors first detected by the attending hospitalists, pharmacists, and consultants were near misses. Drug errors were the most common type of error overall.