- Understanding 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.
A 77-year-old man on anticoagulation for a history of recent deep venous thrombosis presented to the emergency department (ED) with dizziness. In the ED, he had a heart rate of 44 beats per minute, which was felt to explain his symptoms. On further history, he revealed that he had recently increased his beta-blocker, a blood pressure medication that slows the heart.
The ED physician was concerned about the prospect of his heart rate slowing further. She ordered a syringe of atropine be placed at the bedside so it could be injected urgently if he needed it (atropine is a powerful anti-cholinergic medication that is given in emergent situations to raise the heart rate; it can cause rapid heart rate and severe confusion if used inappropriately).
Fortunately, the patient's heart rate improved while he was in the ED, and the plan was to discharge him home on a lower dose of his beta-blocker. Of note, his level of anticoagulation (i.e., his 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 rise into the target range.
The pharmacist came to the ED to teach the patient how to do the subcutaneous LMWH injections, which would be required twice a day. The patient seemed to have some difficulty in understanding the medications, but the pharmacist felt comfortable with the plan to discharge him to home. She gave him 10 syringes pre-filled with the appropriate dose of LMWH to take home until he could be seen in the anticoagulation clinic.
When the patient was packing up everything from the ED, he took not only the boxes of LMWH, but also the box with the syringe of atropine that was still sitting by his bedside.
At home the next day, he tried to inject himself with the atropine but the liquid squirted all over his stomach (the 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 box, she realized what had happened and had him discard the atropine. Fortunately, the patient was not harmed.
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Figure 1. Relationships Among Errors, Adverse Events, Close Calls, and Bad Outcomes.
Note: The figure depicts relationships among errors, adverse events, close calls and bad outcomes. It may also be useful to examine the relationship of errors to patient outcomes. Reprinted from Wu (2), with permission of Joint Commission Resources.
Figure 2. Safety Pyramid.