Table 2.

Summary of near-miss patient safety events reviewed during patient safety curriculum mock root cause analyses

Case (yr)	Patient Safety Event Summary (Session 2)	Mock RCA Conclusions (Session 4)	Mock RCA Recommendations	Resultant System Improvement
Contrast administration before PEG tube placement (2017)	A resident called IR regarding contrast administration before PEG tube placement. IR suggested administering contrast through the patient’s nasogastric tube the night before the planned procedure. The resident placed the order with these instructions, only to realize the day of procedure that the contrast had not been administered.	Residents identified the root cause as the default administration instructions in the EMR that autopopulated when contrast was ordered. These administration instructions called for contrast to be given in the hours before a scan, rather than the night before the procedure as intended.	Collaborate with IR and other stakeholders to learn about current recommendations and best practices for administration of contrast before PEG tube placement.	The PEG tube order panel in the EMR was modified to include specific contrast administration instructions, eliminating the need to use two separate orders and ensuring appropriate contrast administration in the future.
			Revise the PEG tube order panel to include the above recommendations.	The improvement plan was achieved through discussions with IR, EMR analysts, and nursing and was available for use within 3 mo of the mock RCA.
			Minimize the number of orders that need to be placed by combining orders into an order panel.
Pharmacologic prophylaxis against VTE in hospitalized patients (2018)	A patient was admitted with a subdural hematoma and inadvertently given prophylactic enoxaparin on admission.	Residents identified a potential root cause as a hard stop in the EMR admission orders requiring that VTE prophylaxis be addressed. This hard stop was sometimes encountered before a patient’s overall clinical picture was fully understood. Findings were validated through discussions with pharmacy, nursing, ICU attending physicians, and QI and EMR analysts.	Change the admission order set such that physicians do not feel pressured to select pharmacologic VTE prophylaxis in situations of uncertainty.	In the months after the mock RCA, a “defer until bleeding risk assessed” option was added to the admission order set, allowing admitting providers the option to defer decisions about VTE prophylaxis for 12 h.
			Implement an educational initiative for residents and attending physicians who routinely use the admission order sets, including an update about the order-set change, best practices for use of pharmacologic VTE prophylaxis, and when the new order-set options should be used.
Direct hospital admissions with intravenous heparin infusions (2019)	Several patients directly admitted from outside hospitals encountered unintended interruptions in heparin therapy upon arriving to the hospital as a result of transport teams disconnecting the infusion and taking their own pump delivery systems with them. Many of these patients were transferred for management of serious problems such as myocardial infarction. If admitting physicians were unable to place admission orders immediately, re-initiation of the heparin infusion could be delayed.	Residents identified that a nurse-initiated order set had previously been developed to address this scenario but was inconsistently used because of transitions in the workforce and waning awareness.	Implement an educational initiative for physicians, nurses, and other members of the care team on floors that allow for nurse-driven heparin infusion protocols.	Newsletters and e-mail communications were shared with pharmacists, nurses, and physicians, promoting more consistent awareness and order-set use.
				Residents were educated about the order set and encouraged to remind nursing staff to use it when a new admission arrives.
				These interventions were developed and implemented just several months after the mock RCA, and the order set is currently being used.
Pharmacologic prophylaxis against VTE in hospitalized patients (2020)	Because of ongoing patient safety concerns regarding inadvertent administration of pharmacologic VTE prophylaxis (similar to those of the 2018 cohort), residents chose to readdress the case of a patient admitted with intracranial hemorrhage who was unintentionally given prophylactic enoxaparin.	Residents identified the root cause as an incongruency between the admission workflow and the EMR order set. Providers may feel compelled to write admission orders in a timely fashion, but often, the information needed to make an informed decision about pharmacologic VTE prophylaxis is not available at the time a hard stop requires pharmacologic VTE prophylaxis orders to be placed.	Optimize admission order-set language.	The order-set language was changed to “differential diagnosis includes a contraindication for anticoagulation; defer until clinical picture is more clear”; this recommendation was similar to 2018 recommendations.
			Consider a default start time for VTE prophylaxis at several hours after admission to provide a safety margin against inadvertent ordering.	These system changes were in conjunction with other organizational quality initiatives targeted at improving VTE prophylaxis.
			Educate providers about the aforementioned changes, and try to standardize these across all service lines and admission order sets.

Definition of abbreviations: EMR = electronic medical record; ICU = intensive care unit; IR = interventional radiology; PEG = percutaneous gastrostomy; QI = quality improvement; RCA = root cause analysis; VTE = venous thromboembolism.