Sumit Bhagra, MD, an endocrinologist at Mayo Clinic Health System in Albert Lea, Minn., sensed something was wrong as he prepared to perform a needle biopsy on a patient with thyroid nodules. The patient's right side had been prepped but something told Dr. Bhagra to double check the patient's chart, a precaution that prevented a potentially harmful mistake.
“The nurse was taking shortcuts by asking the patient what side they thought they were here for and, even though the chart clearly mentioned it was one side, the wrong site was prepped,” said Dr. Bhagra. “Had we not looked at the chart before doing the procedure, I might have taken the path of least resistance and done the biopsy as planned.”
Dr. Bhagra's quick thinking prompted his colleagues to nominate him for the Minnesota Hospital Association's annual Good Catch for Patient Safety award, which recognizes hospital staff for reporting “near miss” incidents that were caught in time to prevent harm to patients. Mayo also took concrete action based on Dr. Bhagra's report by retraining the prep nurse and reviewing with staff the process and documentation required before procedures.
Mayo's Albert Lea clinic has implemented many changes to improve safety over the past decade based on near miss reports made by employees via its online Patient Safety Zone reporting system. Every time an employee submits a report, a memo is automatically sent to the appropriate unit manager for immediate follow-up. A safety leadership team, which includes the hospital's medical director, reviews all reports weekly to identify trends and recommend changes to systems or workflow.
Other hospitals around the country are reaping the benefits of similar near miss reporting programs—and facing the challenge of convincing employees they won't be punished for reporting. It's definitely worth the effort, said Tonia Lauer, quality administrative officer at the Mayo Clinic in Albert Lea.
“It gives us 1,200 eyes and ears throughout the hospital,” said Ms. Lauer. “It gives us that frontline focus so we catch the things you don't even see unless you're working at the bedside.”
Spotting patterns, identifying risks
While all hospitals accredited under The Joint Commission are expected to report and investigate sentinel events, defined as unexpected occurrences involving death or serious injury, near misses often go unreported.
“Instead of waiting for adverse events to happen, we should collect data on near misses and use a forward looking approach,” said Peter J. Fabri, MD, professor of surgery and of industrial engineering at University of South Florida (USF) Health in Tampa, who spearheaded USF's near miss reporting program five years ago. “You can look at near misses to identify places where you want to invest resources to create systems to prevent adverse events.”
Unlike in sentinel event reporting, a root cause analysis of every near miss is not necessary, just documentation of the basic circumstances surrounding the occurrence, he said. The goal is to spot trends. One near miss report isn't very meaningful but a cluster of reports dealing with a similar type of error can point to areas where adverse events are likely to happen.
As a case in point, a group of near miss reports several years ago involving attempted cholecystectomy in patients who had already had their gall bladders removed prompted the Pennsylvania Patient Safety Reporting System (PA-PSRS) to put out an advisory to all hospitals detailing the risks and suggesting ways to avoid similar problems. In each of the three reports reviewed, the diagnosis relied on ultrasound alone, and the patient was elderly and uncertain about whether their gall bladder had been removed previously.
“They started the procedure and in the middle found out that the patient didn't have a gall bladder,” said William Marella, program director for the patient safety reporting program at ECRI Institute, a federally designated Patient Safety Organization, and director of PA-PSRS. “No one ever writes up that sort of thing in the literature because it's embarrassing, but we were able to see a pattern.”
The goal of collecting near miss reports is to understand why mistakes happen as opposed to assigning blame, said Linda Connell, RN, director of the Aviation Safety Reporting System and the Patient Safety Reporting System (PSRS), a prototype developed in collaboration with the National Aeronautics and Space Administration (NASA) in partnership with the Department of Veterans Affairs (VA) medical system from 2000-2009 (more information is online) .
“Is there a link that could have been part of the chain of events that, if changed, could prevent further incidents?” said Ms. Connell. “People may have felt they did something wrong but in actuality it's probably the system that's not helping them do the right thing.”
Changes made as a result of near miss reports can be simple but meaningful, noted Ms. Lauer at Mayo. For example, one near miss report alerted administrators to a functional problem with a unit's automatic doors, which were closing so quickly that it was impossible for an elderly patient with a walker to get through. “We got someone from engineering up there right away to change the timing on the door,” she said.
Like Mayo's Albert Lea clinic, the University of Connecticut Health Center's John Dempsey Hospital in Farmington, Conn., encourages employees to report by including high-level medical executives on safety teams, recognizing employees for participation, and highlighting the changes made as a result of reports.
“We try to create a blame-free environment,” said Scott Allen, MD, medical director for quality programs at John Dempsey. Any employee can submit an adverse event or near miss report through the hospital's online Patient Safety Net reporting system, which typically receives anywhere from four to 12 reports per day. Every report triggers email alerts to the safety committee members and the appropriate unit manager. In addition, the safety committee meets three times a week with front line staff to discuss how to correct problems.
When submitting a report, employees can choose to remain anonymous, but they must sign their report to be eligible for the hospital's Good Catch award, which is given to several employees each month. A three-member committee, consisting of Dr. Allen, Ann Marie Capo, RN, associate vice president for quality programs, and Pamela Marshalkowski, director of regulatory compliance, reviews nominations for the award and selects winners.
Members of the safety committee go directly to the winner's unit to present the award, which consists of a catcher's mitt lapel pin, an award certificate (copied to their personnel file) and recognition in the staff newsletter.
“It's something to be proud of,” said Ms. Marshalkowski, who chairs the safety committee. “It's become a contest on the units to see who can catch the most things.”
Setting up a reporting program is a first step but the real challenge is getting people to use it, said Dr. Fabri. Many employees simply don't trust that their reports won't be used against them, even when they are promised anonymity.
“We created a system, came up with a standard, computerized method of reporting and it only took an average of 30 seconds to report a near miss. It was totally anonymous and we trained every single employee in the institution how to do it,” said Dr. Fabri. “It still didn't work. We get about two reports a month and we propose that there are probably about 100 [near misses] a week.”
While hospitals such as Mayo and John Dempsey have made strides in creating a culture of trust, they acknowledge that physicians are still hesitant to admit a mistake even if it didn't result in harm to a patient.
“Most doctors still perceive that things will be counted against them or go on their record,” said Mr. Marella. However, that perception can be overcome by consistently demonstrating how the reports are being used in positive ways, he said.
“Often people miss the opportunity to make visible the positive changes that happen as a result of reporting,” he said. “Doctors are very data- and evidence-driven. If they see changes being made in areas that matter to them, that is the most compelling argument to get them to report things.”
For Dr. Bhagra, it's far better to report a near miss incident than to stay quiet and risk being involved in a potentially avoidable adverse event down the road.
Clinicians need to acknowledge that they are “human and prone to error,” said Dr. Bhagra. “Someone speaking up is simply a double check to prevent errors, complications and potential liability in the future. Even though ego and pride might be hurt, the goal should be a culture of speaking up without fear.”