Near Misses

Dr. Chaudhry’s overall recommendation to hospitalists involves the position they hold at this time. “Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting,” she says.

Dr. Weingart tells hospitalist audiences that the most important areas for detecting errors in their practice include safe prescription writing and error-proofing high-risk activities (such as hand-offs and sign-outs, and follow-up of test results). He also recommends that hospitalists play the role of responsible citizens in their institutions and be open to ways your patients can contribute by helping you detect errors in their care.4 These issues will be addressed in more detail in future articles in The Hospitalist.

Although Dr. Chaudhry is no longer practicing as a hospitalist, she believes that hospital teams working closely together in patient care have a strong advantage to identify any errors.

“As physicians, with hospital medicine expanding,” she says, “this is the opportune time to take on a leadership role, and this needs to be part of the hospitalist mission. Not everyone has to come out and report their adverse events, especially since the legal risks are still unclear. But a safe way and equally informative way to work on preventing harm is to focus on those near misses.”

Conclusion

Hospitalists who search for near misses, volunteer this information, and enroll their colleagues in doing the same contribute to reforming systems and processes that will ultimately reduce the potential for all errors. Those who pay close attention to standardized rules for prescription-writing, error-proofing high-risk activities, and their roles for institutional citizenship and encouraging patient contribution in regard to possible errors, are doing the best possible job to prevent harm to patients and the institution as a whole. TH

Andrea Sattinger will write about apology in medicine in the June issue.

References

1. Kohn LT, Corrigan JM, Donaldson MS, Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2. Bleich S. Medical Errors: Five Years After the IOM Report. New York: Commonwealth Fund; July 2005: Available at: www.mihealthandsafety.org/pdfs/pub-4-commonwealth.pdf. Last accessed March 22, 2006.
3. Chaudhry SI, Olofinboba KA, Krumholz HM. Detection of errors by attending physicians on a general medicine service. J Gen Intern Med. 2003 Aug;18(8):595-600.
4. Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med. 2005 Sep;20(9):830-836.