Physician Cross-Checking Reduces Adverse Events in Emergency Departments

Systematic cross-checking between emergency physicians may be a key approach to reducing high rates of adverse events in the emergency department (ED), according to a study published in JAMA Internal Medicine.

Medical errors and adverse events are the third leading cause of death in the United States, and EDs represent a particularly high-risk environment for these to occur.

“In the ED, the care of a patient is often managed by a sole physician,” wrote the authors of the study. “This contrasts with other clinical settings in which patients may benefit from multiple ward rounds, staff meetings, and handovers.”

The authors performed a cluster-randomized crossover trial of 1680 patients from 6 EDs over 2 periods of 10 days a month apart. During the first 10-day period, each ED was assigned to either the intervention or control group. During the second period, the alternative strategy was applied to each.

A systematic cross-checking between emergency physicians was implemented 3 times a day, which included a brief presentation from 1 physician on the patient’s sex, age, chief complaint and main medical history, main clinical findings, treatment given in the ED, and a brief summary of the plan. This was followed by the second physician’s feedback.

There were 382 cross-checking sessions during the intervention period, which identified 573 patients (68%) who were cross-checked during the period. The median duration of sessions was 9 minutes, and a median number of 7 patients were cross-checked during each session.

Of the 1680 patients, 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) who were cross-checked, compared with 90 adverse events among 840 patients (10.7%) in the standard-care group. There was a relative risk reduction (RRR) of 40% in the rate of adverse events.

A near-miss, which was defined as a medical error that has the potential to cause an adverse event, but did not, either by chance or intervention, was identified in 75 (4.5%) patients in the cross-checking group, compared with 49 (5.8%) in the standard-care group. This resulted in a RRR of 47% in the rate of near misses.

Researchers observed no significant reduction in the rate of patients with a serious adverse event in the 7 days following an ED visit, either preventable or not.

According to the researchers, these results benefit from the systematic cross-checking allowing a higher fraction of patients to get an opinion from a second physician. The implementation of checklists was also reported to reduce the rate of medical error.

“It is likely that systematic cross-checking reduced the rate of adverse events errors by allowing a reevaluation of the patient by the peer cross-checker, who is able to cast a fresh eye on the patient’s management,” wrote the authors. “Moreover, the cross-checks may have forced the physician to reconsider his or her initial diagnosis and management plan and, in turn, intercept an error.”

The researchers did note that, due to the retrospective nature of their analysis, it was difficult to determine the exact nature of the error leading to an adverse event.