Spotlight Case

1. Spotlight Case Near Miss with Bedside Medications

2. Source and Credits • This presentation is based on the November 2011AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg School of Public Health • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the definition of near miss—also known as close call • Appreciate the importance of close calls in reducing adverse events • Describe the role of incident reporting in the handling of close calls, and what should be done after discovering a close call

4. Case: Near Miss A 77-year-old man on anticoagulation for recent deep venous thrombosis presented to the emergency department (ED) with dizziness. His heart rate was 44 beats per minute, which was felt to explain his symptoms. Further history revealed that he had recently increased his beta-blocker, a blood pressure medication that slows the heart. Concerned about the patient’s heart rate slowing further, the ED physician ordered a syringe of atropine be placed at the bedside to be injected urgently if needed (atropine is given in emergent situations to raise the heart rate).

5. Case: Near Miss (2) The patient’s heart rate improved in the ED, and the plan was to discharge him home on a lower dose of beta-blocker. Of note, his level of anticoagulation (i.e., international normalized ratio [INR]) on warfarin (oral blood thinner) was found to be low. So, along with decreasing his beta-blocker dose, the plan included having him inject himself with low-molecular-weight heparin (LMWH) at home for a few days to ensure adequate anticoagulation while waiting for his INR to reach the target range.

6. Case: Near Miss (3) The pharmacist came to the ED to teach the patient how to do subcutaneous LMWH injections, which would be needed twice daily. Although the patient seemed to have some difficulty in understanding the medications, the pharmacist felt comfortable with the discharge plan. She gave him 10 syringes pre-filled with the appropriate dose of LMWH to take at home until his appointment in the anticoagulation clinic. When packing up everything from the ED, the patient took not only the LMWH, but also the syringe of atropine that was still sitting by the bedside.

7. Case: Near Miss (4) At home the next day, the patient tried to inject himself with the atropine, but the liquid squirted all over his stomach (atropine syringe does not have a needle, as it is usually injected directly into a peripheral IV). Confused, he called the pharmacist. When the pharmacist had him spell the name on the label, she realized what had happened and had him discard the atropine. Fortunately, the patient was not harmed.

8. Background: Near Miss • Multiple errors in this case • Fortunately, patient was not harmed • This case can be defined as a near miss • Near misses are unsafe acts that have the potential to injure a patient, but do not

9. Background: Near Miss (2) • Near misses are also called close calls • Include two different scenarios: • Incidents that have potential to cause harm but never reach the patient • Incidents that have potential to cause harm, reach the patient, but do not cause harm See Notes for references.

10. Incidence of Near Misses • It is unclear how common near misses are relative to errors or adverse events • It has been estimated that for each preventable death, there are between 7−100 close calls • For example, the Pennsylvania Patient Safety Reporting System collects more than 200,000 reports per year, 97% of which are close-calls See Notes for references.

11. Advantages of Studying Close Calls • Close calls provide information on different types of errors • Near misses are much more common, providing more opportunities to examine the system • They are less fraught with emotion and may be easier to study • Close calls allow for examining recovery strategies in situ

12. Identifying Near Misses • Many ways to identify near misses • Direct reporting by health care workers is most common; can be by multiple means: • Paper-based • Email communication • Anonymous phone lines • Online reporting (likely the most effective) • Patients and families can also be encouraged to report near misses See Notes for reference.

13. Identifying Near Misses (2) • Near misses may also be identified through active clinical monitoring • Active monitoring occurs when key data collection is built into the clinical process. Examples include: • Charting of vital signs in OR by anesthesiologists • Systematic recording of erroneously written prescriptions • Requiring a checklist be completed before central line placement and including this in the medical record

14. Identifying Near Misses (3) • Active clinical monitoring may be automated to record data and detect errors • Examples are “smart pumps” (infusion pump that alerts operators when it is infusing outside of pre-configured limits) and barcoding for medication administration

15. Managing This Case • A formal review and analysis should include: • Incident should be formally documented and recorded (then analyzed with other similar incidents) • A detailed investigation should include gathering information from all frontline health care workers • The incident should be discussed the patient safety committee or other management team • If solutions are implemented, they should be evaluated in the future See Notes for references.

16. Responses to This Case • Patient safety committee recommended that: • Ordering template for “bedside” medications be modified to include a discontinuation time • ED procedure be modified so that, at discharge, all medications are packed together under nurse supervision • Pharmacy add a warning label to injectable cardioactivemedications

17. Take-Home Points • Some errors result in patient harm, while others do not. Close calls (near misses) are errors that do not result in harm. • Close calls are much more common than adverse events, although the true incidence is not known. Because they are more frequent, they are useful to study. • Studying close calls allows capture and analysis of recovery strategies that can help prevent harm.

18. Take-Home Points (2) • Patient safety reporting systems (incident reporting systems) are necessary to record and analyze close calls. • To derive benefit from a close call, it must be recorded, analyzed, something must be done about it, and the intervention must be evaluated.