Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department

Abstract

IMPORTANCE Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved.OBJECTIVE To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized crossover trial includes a random sample of 14 adult patients (age Ն18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France.INTERVENTIONS Systematic cross-checking between emergency physicians, 3 times a day, which included a brief presentation of one physician's case to another, followed by the second physician's feedback to the first. MAIN OUTCOMES AND MEASURESMedical error in the ED, defined as an adverse event (either a near miss or a serious adverse event). The primary end point was identified using a 2-level error detection surveillance system, blinded to the strategy allocation. RESULTS Among the 1680 included patients (mean [SD] age, 57.5 [21.7] years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) in the cross-check group compared with 90 adverse events among 840 patients (10.7%) in the standard care group (relative risk reduction [RRR], 40% [95% CI, 12% to 59%]; absolute risk reduction [ARR], 4.3%; number needed to treat [NNT], 24). There was also a significant reduction rate of near misses (RRR, 47% [95% CI, 15% to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of preventable serious adverse events (RRR, 29% [95% CI, −18% to 57%]; ARR, 1.2%; NNT, 83). CONCLUSIONS AND RELEVANCEThe implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses.

Systematic physician cross-checking between emergency department physicians is associated with a significant reduction in adverse events

“…This study1 provides additional support for the potential benefit of discussing patient cases with colleagues in order to reduce the risk of near misses and potential patient harm. This is reassuring for the majority of clinicians whose day-to-day work in a hospital setting involves frequent discussions with colleagues about patient care, during ward rounds, multidisciplinary meetings and when referring to specialist teams.…”

MOdified DIagnostic strateGy to safely ruLe-out pulmonary embolism In the emergency depArtment: study protocol for the Non-Inferiority MODIGLIANI cluster cross-over randomized trial

“…(according to the ISTH recommendations so the upper bound of the 95% confidence interval (CI) of the failure rate in the intervention group will not exceed 1.85%), beta = 20%, and one-sided alpha = 2.5%, N1 = 857 patients are needed (East 6, Cytel, Cambridge, MA, USA). Under the assumption of an intra-class correlation coefficient (CCIC) of 0.018, an interperiod correlation (η) of 0.0115 (based on previous cluster randomized trials in French EDs) and a mean cluster size for one period (m) = 22 patients, the cluster design effect would be 1.37 [17,20]. Considering 5% of non-evaluable patients, with 18 centers and two periods, 1234 patients are needed.…”

Que peuvent apporter les sciences humaines et sociales à la recherche en médecine d’urgence ?

“…Ainsi, l'étude CHARMED a montré une diminution significative du risque d'erreur médicale par l'introduction de vérifications croisées systématiques entre médecin. Ces séances de cross-checking, implémentées toutes les 2-3 heures et d'une durée inférieure à 10 minutes par médecin permettaient de diminuer de 10 % à 6 % le risque d'erreur médicale aux urgences [28].…”