Patient Safety and Quality

Close-call reporting systems may be underutilized in identifying potential medical errors

Health care providers are less likely to identify close calls than medical errors, perhaps hampering the effectiveness of close-call and near-miss reporting systems, suggests a study supported by the Agency for Healthcare Research and Quality (HS11544). Close calls or near-misses are potential medical errors that do not result in patient harm, therefore, they are less noticeable and more difficult to identify. University of Texas researchers asked 68 health care providers (22 doctors, 23 nurses, 13 pharmacists, and 10 physician assistants) from a large, academic medical center to evaluate 5 hypothetical errors and 5 close-call scenarios based on actual errors and close calls from the institution. Half of the participants in each group received definitions of errors and close calls before reading each scenario and half did not.

The percentage of scenarios categorized correctly by health care professionals for close calls and errors, respectively, was: 67.8 percent and 74.8 percent for nurses, 73.8 percent and 78.5 percent for pharmacists, 74 percent and 80 percent for physician assistants, and 67.6 percent and 78.2 percent for physicians. Health care providers accurately categorized errors 77.1 percent of the time without definitions, but accurately categorized close calls only 62.9 percent of the time without definitions.

The finding that nearly 40 percent of providers could not correctly identify close calls without a definition underscores the need for health care organizations to implement reporting systems to clearly define close-call events during training sessions. Close calls can occur as much as 300 times more often than errors. As such, providers may correct close calls while they accomplish their tasks, rather than stop and report these situations. Because providers do not correctly view these situations as potential problems, close calls might be underreported.

See "Differentiating close calls from errors: A multidisciplinary perspective," by Jason M. Etchegaray, Ph.D., Eric J. Thomas, M.D., Jane M. Geraci, M.D., and others, in the September 2005 Journal of Patient Safety 1(3), pp. 133-137.

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