Sharon K. Martin

Differentiating close calls from errors: A multidisciplinary perspective

Objectives: To investigate the ability of health care providers to correctly identify close calls and errors and to examine the role of close call and error definitions on such identification. Methods: Sixty-eight health care providers from a large, academic medical center institution participated (22 physicians, 23 nurses, 13 pharmacists, and 10 physician assistants). Five hypothetical errors and 5 close call scenarios were developed based upon actual errors and close calls from the institution. Each participant was provided with all 10 scenarios to evaluate. Additionally, to determine the importance of including a definition of a close call or error, participants were randomly assigned to 1 of 2 groups: group 1 received definitions of errors and close calls before reading each scenario, whereas group 2 did not receive these definitions. After reading each scenario, providers classified the scenarios as errors, close calls, or neither. Results: The majority of participants correctly identified close call and error scenarios. The percentage of scenarios categorized correctly by profession for close calls and errors, respectively, was: 67.8% and 74.8% for nurses, 73.8% and 78.5% for pharmacists, 74% and 80% for physician assistants, and 67.6% and 78.2% for physicians. Participants with definitions of close calls were significantly more likely to identify them correctly than participants without definitions (t(65) = 2.303, P < 0.05). The same finding was not replicated for error scenarios (t(66) = 0.149, P > 0.05). Conclusions: The rate of incorrectly identifying close calls, although relatively low, suggests that close call reporting systems might be underutilized due to provider knowledge about these medical situations. The findings provide support for the need to educate providers about close calls to maximize the likelihood of receiving close call reports.