Lessons Learned from a Major Near Miss: A Case Report Including Recommendations to Improve Future Patient Safety in Rehabilitation

Background: Most medical errors can be traced to system failure, but often individual providers are blamed. Few articles in the allied health literature address the topic of error or the analysis of error using a system approach. Purpose: This case report analysis illustrates how both individual and system factors contribute to error in rehabilitation settings and how identification of these factors allows development of methods to improve future patient safety. Case Description: A young male was admitted to a rehabilitation hospital with residual impairments following recent surgical resection of a benign meningioma. He was treated daily by a physical therapist intern as part of a large interdisciplinary team. On separate occasions over a three week span, the patient presented with isolated calf tightness, right-sided and central chest pain, and fever with increased heart rate. Although the intern considered possible deep vein thrombosis (DVT), each symptom was attributed to other causes by the intern, supervising physical therapist, physician assistant, and/or physician (i.e. muscle fatigue, heartburn, infection). On day 22, the patient was diagnosed with DVT and pulmonary embolism (PE). This event represents a major near miss due to the potential deadly outcomes of a missed DVT/PE diagnosis. The intern retrospectively completed an analysis of the event to identify contributing system factors. Outcome of Analysis: Active failures and latent system conditions on multiple levels of the healthcare system were identified as contributors to the major near miss. Discussion: The contributing factors identified in this paper are not unique to this case, intern, or facility, and may be widespread across rehabilitation settings and practitioners. Team members can and should consider how system-wide factors contribute to their own clinical actions and decisions. Once factors are identified, strategies for reducing risk can be implemented; ultimately creating a culture of safety