New Cardiothoracic Safety Reporting for 'Near Misses'

Many residents are unaware that a near miss reporting site for cardiothoracic surgery exists, the Cardiothoracic Safety Reporting System. This system, available through the CTSNet website (http://ctsrs.ctsnet.org/) allows anyone with a CTSNet login to submit descriptions of near misses and review the near misses others have submitted, ranging from labeling errors to a case of an ascending aortic graft igniting during a Bentall procedure.

By way of background, it has been estimated that about 100,000 people die avoidable deaths annually in U.S. hospitals, and many more incur injuries to the tune of an annual cost of approximately $9 billion; this exceeds the combined number of deaths and injuries from automobile and airplane crashes, suicides, poisonings, drownings and falls annually (BMJ 2000; 320(7237): 759-63). To reduce this number of errors requires learning not only from the times harm resulted to patients from errors, but also the cases where an error occurred but negative consequences were averted, a “near miss.”

As surgeons, we are accustomed to the discussion of our errors in regular morbidity and mortality conferences. Conferences such as these are invaluable for learning and practice improvement, but are limited in that they focus on actual adverse events, with near-misses rarely discussed. And, since only the participants present at the conferences learn the lessons to be gleaned from these events, the impact of conferences such as this are narrow.

In other disciplines, industry-wide schemes for reporting “close calls,” near misses, or sentinel (“warning”) events have been created. The near-miss reporting system in aviation, the Aviation Reporting Safety System (http://asrs.arc.nasa.gov/), is well-known, but similar systems are in place in the nuclear power industry, the military, petrochemical processing and steel production, high-reliability organizations which function in “high consequence” environments (www.ctsnet.org/sections/newsandviews/specialreports/article-10.html).

With these examples in mind, in 2007 the STS's Workforce for Patient Safety, at the time under the leadership of Dr. Thor Sundt, created the Cardiothoracic Safety Reporting System. Dr. Sundt, Dr. Marshall Blair, the current chair of the Workforce, and Dr. Emile Bacha, who was involved in the early planning and discussion of this project, recently approached the Thoracic Surgery Residents' Association (TSRA) regarding increasing resident participation in the effort. In TSRA internal discussions about the site, the chief concern was the anonymity of those who submitted cases.

Although CTSNet login information is required to access the site, it is electronically scrambled so that the users identity is “unobtainable and untraceable through any means, even if CTSNet wanted to try to find that information, they could not,” said Dr. Marshall. “It is scrambled to the extent that even if the Supreme Court ordered CTSNet to divulge the data, CTSNet would be unable to do so because they simply do not have that data; it doesn't exist anywhere,” explained Dr. Sundt.

Furthermore, the cases submitted are modified to remove any data that is identifiable and only those with CTSNet logins can review the cases. It is also important to recognize that by definition, no legally actionable material can be submitted; for legal reasons; no actual harm to a patient can have occurred for a case to be considered a “near miss.”

What is to be gained by submitting cases to the site? “Everybody makes mistakes … there's an old saying that a mistake is only a mistake when you don't learn from it. The purpose of a site like this is to share your mistakes and have other people benefit from it - that is something good that can come out of an otherwise bad situation. In a near miss, there is no harm to the patient, but we still can benefit.

“The idea is to move outside the team-centric morbidity and mortality conference type of sharing to a sharing with the rest of the field things that would benefit everybody and by doing this to end up avoiding that problem in a different place - how great is that?” said Dr. Bacha. “And, the more robust the site becomes, the more the field would benefit,” he continued.

Besides these altruistic benefits, those who review the site can also learn from the cases others have submitted. Visitors will see that previously submitted cases have been analyzed by a human factors expert, who provided useful commentary on the situations described. Dr. Marshall has analyzed all of the cases submitted to date and has found that they are split about 50/50 between labeling and device/equipment errors.

For instance, Dr. Marshall described a case of a labeling error in the context of transplantation. In this case, both the heart and lungs were procured at one institution but when the heart and lung teams arrived at their home institutions, they found they had brought the wrong cooler back with them; the heart team had the lungs and the lung team had the heart.

As it turned out, the organs went to neighboring institutions so the error was easily rectified, but this was an obvious near miss with a practical, easy to implement solution: label your coolers.

There is a lot to be gained from this project with very little downside; “it's very easy to submit cases, it is very straightforward and totally anonymous” said Dr. Marshall “and the more cases we have, the more we can learn.”

Many residents are unaware that a near miss reporting site for cardiothoracic surgery exists, the Cardiothoracic Safety Reporting System. This system, available through the CTSNet website (http://ctsrs.ctsnet.org/) allows anyone with a CTSNet login to submit descriptions of near misses and review the near misses others have submitted, ranging from labeling errors to a case of an ascending aortic graft igniting during a Bentall procedure.

By way of background, it has been estimated that about 100,000 people die avoidable deaths annually in U.S. hospitals, and many more incur injuries to the tune of an annual cost of approximately $9 billion; this exceeds the combined number of deaths and injuries from automobile and airplane crashes, suicides, poisonings, drownings and falls annually (BMJ 2000; 320(7237): 759-63). To reduce this number of errors requires learning not only from the times harm resulted to patients from errors, but also the cases where an error occurred but negative consequences were averted, a “near miss.”

As surgeons, we are accustomed to the discussion of our errors in regular morbidity and mortality conferences. Conferences such as these are invaluable for learning and practice improvement, but are limited in that they focus on actual adverse events, with near-misses rarely discussed. And, since only the participants present at the conferences learn the lessons to be gleaned from these events, the impact of conferences such as this are narrow.

In other disciplines, industry-wide schemes for reporting “close calls,” near misses, or sentinel (“warning”) events have been created. The near-miss reporting system in aviation, the Aviation Reporting Safety System (http://asrs.arc.nasa.gov/), is well-known, but similar systems are in place in the nuclear power industry, the military, petrochemical processing and steel production, high-reliability organizations which function in “high consequence” environments (www.ctsnet.org/sections/newsandviews/specialreports/article-10.html).

With these examples in mind, in 2007 the STS's Workforce for Patient Safety, at the time under the leadership of Dr. Thor Sundt, created the Cardiothoracic Safety Reporting System. Dr. Sundt, Dr. Marshall Blair, the current chair of the Workforce, and Dr. Emile Bacha, who was involved in the early planning and discussion of this project, recently approached the Thoracic Surgery Residents' Association (TSRA) regarding increasing resident participation in the effort. In TSRA internal discussions about the site, the chief concern was the anonymity of those who submitted cases.

Although CTSNet login information is required to access the site, it is electronically scrambled so that the users identity is “unobtainable and untraceable through any means, even if CTSNet wanted to try to find that information, they could not,” said Dr. Marshall. “It is scrambled to the extent that even if the Supreme Court ordered CTSNet to divulge the data, CTSNet would be unable to do so because they simply do not have that data; it doesn't exist anywhere,” explained Dr. Sundt.

Furthermore, the cases submitted are modified to remove any data that is identifiable and only those with CTSNet logins can review the cases. It is also important to recognize that by definition, no legally actionable material can be submitted; for legal reasons; no actual harm to a patient can have occurred for a case to be considered a “near miss.”

What is to be gained by submitting cases to the site? “Everybody makes mistakes … there's an old saying that a mistake is only a mistake when you don't learn from it. The purpose of a site like this is to share your mistakes and have other people benefit from it - that is something good that can come out of an otherwise bad situation. In a near miss, there is no harm to the patient, but we still can benefit.

“The idea is to move outside the team-centric morbidity and mortality conference type of sharing to a sharing with the rest of the field things that would benefit everybody and by doing this to end up avoiding that problem in a different place - how great is that?” said Dr. Bacha. “And, the more robust the site becomes, the more the field would benefit,” he continued.

Besides these altruistic benefits, those who review the site can also learn from the cases others have submitted. Visitors will see that previously submitted cases have been analyzed by a human factors expert, who provided useful commentary on the situations described. Dr. Marshall has analyzed all of the cases submitted to date and has found that they are split about 50/50 between labeling and device/equipment errors.

For instance, Dr. Marshall described a case of a labeling error in the context of transplantation. In this case, both the heart and lungs were procured at one institution but when the heart and lung teams arrived at their home institutions, they found they had brought the wrong cooler back with them; the heart team had the lungs and the lung team had the heart.

As it turned out, the organs went to neighboring institutions so the error was easily rectified, but this was an obvious near miss with a practical, easy to implement solution: label your coolers.

There is a lot to be gained from this project with very little downside; “it's very easy to submit cases, it is very straightforward and totally anonymous” said Dr. Marshall “and the more cases we have, the more we can learn.”

Many residents are unaware that a near miss reporting site for cardiothoracic surgery exists, the Cardiothoracic Safety Reporting System. This system, available through the CTSNet website (http://ctsrs.ctsnet.org/) allows anyone with a CTSNet login to submit descriptions of near misses and review the near misses others have submitted, ranging from labeling errors to a case of an ascending aortic graft igniting during a Bentall procedure.

By way of background, it has been estimated that about 100,000 people die avoidable deaths annually in U.S. hospitals, and many more incur injuries to the tune of an annual cost of approximately $9 billion; this exceeds the combined number of deaths and injuries from automobile and airplane crashes, suicides, poisonings, drownings and falls annually (BMJ 2000; 320(7237): 759-63). To reduce this number of errors requires learning not only from the times harm resulted to patients from errors, but also the cases where an error occurred but negative consequences were averted, a “near miss.”

As surgeons, we are accustomed to the discussion of our errors in regular morbidity and mortality conferences. Conferences such as these are invaluable for learning and practice improvement, but are limited in that they focus on actual adverse events, with near-misses rarely discussed. And, since only the participants present at the conferences learn the lessons to be gleaned from these events, the impact of conferences such as this are narrow.

In other disciplines, industry-wide schemes for reporting “close calls,” near misses, or sentinel (“warning”) events have been created. The near-miss reporting system in aviation, the Aviation Reporting Safety System (http://asrs.arc.nasa.gov/), is well-known, but similar systems are in place in the nuclear power industry, the military, petrochemical processing and steel production, high-reliability organizations which function in “high consequence” environments (www.ctsnet.org/sections/newsandviews/specialreports/article-10.html).

With these examples in mind, in 2007 the STS's Workforce for Patient Safety, at the time under the leadership of Dr. Thor Sundt, created the Cardiothoracic Safety Reporting System. Dr. Sundt, Dr. Marshall Blair, the current chair of the Workforce, and Dr. Emile Bacha, who was involved in the early planning and discussion of this project, recently approached the Thoracic Surgery Residents' Association (TSRA) regarding increasing resident participation in the effort. In TSRA internal discussions about the site, the chief concern was the anonymity of those who submitted cases.

Although CTSNet login information is required to access the site, it is electronically scrambled so that the users identity is “unobtainable and untraceable through any means, even if CTSNet wanted to try to find that information, they could not,” said Dr. Marshall. “It is scrambled to the extent that even if the Supreme Court ordered CTSNet to divulge the data, CTSNet would be unable to do so because they simply do not have that data; it doesn't exist anywhere,” explained Dr. Sundt.

Furthermore, the cases submitted are modified to remove any data that is identifiable and only those with CTSNet logins can review the cases. It is also important to recognize that by definition, no legally actionable material can be submitted; for legal reasons; no actual harm to a patient can have occurred for a case to be considered a “near miss.”

What is to be gained by submitting cases to the site? “Everybody makes mistakes … there's an old saying that a mistake is only a mistake when you don't learn from it. The purpose of a site like this is to share your mistakes and have other people benefit from it - that is something good that can come out of an otherwise bad situation. In a near miss, there is no harm to the patient, but we still can benefit.

“The idea is to move outside the team-centric morbidity and mortality conference type of sharing to a sharing with the rest of the field things that would benefit everybody and by doing this to end up avoiding that problem in a different place - how great is that?” said Dr. Bacha. “And, the more robust the site becomes, the more the field would benefit,” he continued.

Besides these altruistic benefits, those who review the site can also learn from the cases others have submitted. Visitors will see that previously submitted cases have been analyzed by a human factors expert, who provided useful commentary on the situations described. Dr. Marshall has analyzed all of the cases submitted to date and has found that they are split about 50/50 between labeling and device/equipment errors.

For instance, Dr. Marshall described a case of a labeling error in the context of transplantation. In this case, both the heart and lungs were procured at one institution but when the heart and lung teams arrived at their home institutions, they found they had brought the wrong cooler back with them; the heart team had the lungs and the lung team had the heart.

As it turned out, the organs went to neighboring institutions so the error was easily rectified, but this was an obvious near miss with a practical, easy to implement solution: label your coolers.

There is a lot to be gained from this project with very little downside; “it's very easy to submit cases, it is very straightforward and totally anonymous” said Dr. Marshall “and the more cases we have, the more we can learn.”