Article Text
Abstract
Studying near-miss errors is essential to preventing errors from reaching patients. When an error is committed, it may be intercepted (near-miss) or it will reach the patient; estimates of the proportion that reach the patient vary widely. To better understand this relationship, we conducted a retrospective cohort study using two objective measures to identify wrong-patient imaging order errors involving radiation, estimating the proportion of errors that are intercepted and those that reach the patient. This study was conducted at a large integrated healthcare system using data from 1 January to 31 December 2019. The study used two outcome measures of wrong-patient orders: (1) wrong-patient orders that led to misadministration of radiation reported to the New York Patient Occurrence Reporting and Tracking System (NYPORTS) (misadministration events); and (2) wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder (RAR) measure, a measure identifying orders placed for a patient, retracted and rapidly reordered by the same clinician on a different patient (near-miss events). All imaging orders that involved radiation were extracted retrospectively from the healthcare system data warehouse. Among 293 039 total eligible orders, 151 were wrong-patient orders (3 misadministration events, 148 near-miss events), for an overall rate of 51.5 per 100 000 imaging orders involving radiation placed on the wrong patient. Of all wrong-patient imaging order errors, 2% reached the patient, translating to 50 near-miss events for every 1 error that reached the patient. This proportion provides a more accurate and reliable estimate and reinforces the utility of systematic measure of near-miss errors as an outcome for preventative interventions.
- Near miss
- Adverse events, epidemiology and detection
- Medical error, measurement/epidemiology
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Footnotes
Contributors JK-H and JRA contributed to concept of the study; JK-H and EG collected the data; CBS, JK-H, EG and AKDC conducted the statistical analysis; CBS, JK-H, JRA, NE, JW and JSA contributed the interpretation of the findings; JK-H wrote the initial draft. JRA, JSA, AKDC, CBS, NE, JW and JSA revised the manuscript. JSA is the guarantor and corresponding author. JSA attests that all listed authors meet the authorship criteria.
Funding This project was supported by grant number T32HS026121 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.