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magine this scenario: A patient is anesthetized and incorrectly prepared for surgery on his right leg. In the operating room, during a final check of the patient's X-rays, the surgeon realizes the film was accidentally reversed. The surgery should be performed on his left leg.

While this hypothetical example of a "near miss" did not hurt anyone, it could have led to a dangerous situation. Addressing and eliminating the causes of such events is the focus of a new Columbia project being led by Dr. Harold Kaplan, professor of clinical pathology.

Eradicating the causes of near misses may prevent more serious medical errors that cause death or harm because the two types of occurrences have very similar roots, Dr. Kaplan says. Studies have estimated that between 44,000 and 98,000 people die each year due to medical errors, although the numbers have been disputed. The mistakes add approximately $33 billion annually to nationwide healthcare costs. "And there are many more near-miss events than those with very bad outcomes," Dr. Kaplan says.

Dr. Kaplan's project, called "Reporting Systems and Learning: Best Practices," focuses initially on expanding two error-reporting systems used by New York-Presbyterian Hospital. Funded by a $2.3 million grant from the Department of Health and Human Services Agency for Healthcare Research and Quality for the first year of the study, the overall effort is a collaboration among Columbia University, New York-Presbyterian Hospital, Cornell University, and the University of Chicago Hospitals and Healthsystem. The grant is the second largest from the agency, which is spending $50 million to fund 94 research projects across the country to reduce medical errors and improve patient safety.

In the new program, the researchers will extend to other areas of healthcare the existing Medical Event Reporting System for Transfusion Medicine (MERS-TM), which was developed under a grant from the National Heart, Lung and Blood Institute. MERS-TM is a voluntary initiative healthcare professionals use to monitor near misses and possible mistakes associated with transfusions. The integration of this voluntary system with a state-mandated incident reporting system for serious events, called the New York Patient Occurrence Reporting and Tracking System, also will be evaluated.

"With the new system, we want to create a culture in which doctors, nurses, and other healthcare professionals feel comfortable to report on a voluntary basis near misses as well as mistakes," Dr. Kaplan says. "We are focusing on near misses because they alert us to more serious problems that we hope to prevent. Patients also will be able to report errors under this program."

The program has educational, data collection, and evaluation components. The investigators first will offer training to staff members about how to report their own mistakes and mistakes of others in a non-punitive fashion. The Allen Pavilion, selected units within New York-Presbyterian Hospital, and the University of Chicago healthcare system will be the first test sites early this year. The program will progressively include all of New York-Presbyterian Hospital, seven hospitals in the New York-Presbyterian system, and 10 New York-Presbyterian Hospital ambulatory care network sites.

Once the reporting system is in place with its associated analytic system and corrective actions, the investigators will determine if near misses and events with potential for harm show the expected decrease. Experience with systems such as the MERS transfusion system revealed an initial increase in event reporting during the first phase of program implementation, Dr. Kaplan says. But, in time, errors actually decreased as a result of better events monitoring and corrective action implementation.

Patients also will have an opportunity to report events in the outpatient environment. They will be able to use a telephone hotline, the Internet, and paper-based forms to notify the program managers of any events. "There's an increasing awareness that patients can play an active role in their own healthcare and add to the healthcare experience by being knowledgeable," Dr. Kaplan says.

Some of the ultimate goals of the project are to demonstrate the value of reporting by showing its effects on patient safety, organizational culture, and economic outcomes. Other aims are to find out what kinds of safety information and distribution methods are best for consumers, purchasers, policy-makers, providers, and regulatory agencies.

The new system will capture data in a standardized way and will allow risk managers and quality assurance staff to analyze and compare data more easily. "The system will allow users to analyze their own data and also compare that against the aggregate data from other hospitals," Dr. Kaplan says.

For analysis purposes, the reporting system will use "case-based reasoning," an informatics technique that aims to create a more effective means of spotting emerging trends. The old system relied on employing identical matches of circumstances surrounding an error, limiting the scope of an inquiry. The new technique gathers identical and similar circumstances around an event, making it a more robust way to find mistakes, their causes, and ways to prevent them. "Similar situations often contain solutions to problems such as the follow-up actions taken as a result of an event," Dr. Kaplan says.

Some of Dr. Kaplan's collaborators on the project from P&S, the Mailman School of Public Health, Cornell's Weill Medical College, and New York-Presbyterian Hospital are Dr. Mark Callahan, Dr. Emilio Carrillo, Dr. Mary Cooper, Barbara Rabin Fastman, Dr. Annetine Gelijns, Dr. Eliot Lazar, Dr. Walid Michelen, and Dr. Alan Moskowitz.

Dr. Kaplan acknowledges that some healthcare professionals might have resistance to the program because it could create an additional burden for them. But he hopes they will see that this approach enhances the effectiveness of patient safety efforts. "We want to engage every level of hospital staff to give them a sense of ownership with the reporting system," Dr. Kaplan says. "Patient and employee safety are important for everyone."

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