Effect of systematic physician cross-checking on reducing adverse events in the emergency department the CHARMED cluster randomized trial

Abstract

IMPORTANCE: Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved. OBJECTIVE: To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized crossover trial includes a random sample of 14 adult patients (age ≥18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France. INTERVENTIONS: Systematic cross-checking between emergency physicians, 3 times a day, which included a brief presentation of one physician's case to another, followed by the second physician's feedback to the first. MAIN OUTCOMES AND MEASURES; Medical error in the ED, defined as an adverse event (either a near miss or a serious adverse event). The primary end point was identified using a 2-level error detection surveillance system, blinded to the strategy allocation. RESULTS: Among the 1680 included patients (mean [SD] age, 57.5 [21.7] years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) in the cross-check group compared with 90 adverse events among 840 patients (10.7%) in the standard care group (relative risk reduction [RRR], 40% [95%CI, 12%to 59%]; absolute risk reduction [ARR], 4.3%; number needed to treat [NNT], 24). There was also a significant reduction rate of near misses (RRR, 47%[95%CI, 15%to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of preventable serious adverse events (RRR, 29% [95%CI, -18%to 57%]; ARR, 1.2%; NNT, 83). CONCLUSIONS AND RELEVANCE: The implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses.