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'Near misses' undergo examination in efforts to avoid medical mistakes

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CHICAGO—Several changes made in the medical arena since the Institute of Medicine's groundbreaking 1999 report on medical errors are helping to prevent costly hospital mistakes, but the work must continue, experts say.

One particular change that is garnering attention is the practice of documenting "near misses," or incidents in which a mistake could have occurred but did not as a result of efforts to avoid the potential error, they said.

The topic was discussed during a session at the Professional Liability Underwriting Society's annual Medical Professional Liability Symposium in Chicago by a panel of hospital risk managers, an insurance underwriter and a consultant who examined the state of patient safety in medical practice today.

The Institute of Medicine's 1999 study, "To Err is Human: Building a Safer Health System," highlighted a then-startling statistic: 98,000 people die each year from medical errors, causing more deaths than car accidents, breast cancer or AIDS. The report documented mistakes such as medication overdoses, drug mix-ups and even one patient's case in which the wrong leg was amputated.

That 312-page report, said Ronni Soloman, executive vp and general counsel for the Emergency Care Research Institute in Plymouth Meeting, Pa., served as a catalyst for changes in the medical arena that are ongoing. As a result, she said, instances of medical errors have declined.

Currently, more than 20 U.S. states have medical safety reporting systems to document mistakes made at hospitals and clinics.

Pennsylvania, for example, has a system that documents up to 16,000 mistakes and near misses per month, Ms. Soloman said, with most incidents being near misses. Pennsylvania, she said, is the only state that requires hospitals to record potential errors--information that becomes invaluable when trying to enhance patient safety.

For example, one report filed by a nurse noted that packages for different sizes of syringes looked nearly identical, which could cause a practitioner or nurse to give someone a tenfold overdose of insulin. In another instance, one report found that color-coded wrist bands given to patients to alert medical staff of an anomaly, allergy or special need meant different things at different hospitals. For example, a blue wristband alerts medical staff at one hospital that a patient has a pacemaker; at another hospital, the blue wristband on the patient denotes "allergic to latex."

While states are on the forefront of documenting medical confusion and errors, hospitals also are taking steps to prevent mistakes.

Alexian Bros. Hospital Network in Arlington Heights, Ill., is one medical system that has created a focus on patient safety. More information is being shared among workers at the system's eight facilities northwest of Chicago and more attention is being paid to practices or issues that could lead to major errors, said Diana Woytko, vp of patient safety and quality.

The system has a number of committees that meet several times a month to go over reports that document mistakes and near misses. Ms. Woytko said the data on near misses has played a large role in enhancing patient safety.

"We can react to instances as they occur but patient safety is much more than that," she said. "Here, we're saying let's fix it before it actually happens."