Texas Hospitals Use Close-Call Reporting System Developed Through AHRQ Grant

Patient Safety
May 2006

The Close Call Reporting System (CCRS), a patient safety and quality assurance mechanism developed by the University of Texas Center of Excellence for Patient Safety Research and Practice, is currently being used by 10 hospitals—nine in Texas; one in New York. Developed through an AHRQ grant, CCRS is a voluntary and anonymous tool designed to gather information about "close calls,"which are situations that could have resulted in an accident, injury, or illness, but did not either because of timely intervention or by chance. Close calls are considered medical errors that are corrected before reaching the patient.

CCRS is based on an error reporting system used in commercial aviation, the Aviation Safety Action Program. Through April 2006, 2,750 close calls have been reported via CCRS, and five close call alerts have been sent to participating hospitals, the FDA, and the United States Pharmacopeia regarding close calls related to labeling and packaging of medications. Participating hospitals are using the data to inform and guide their own quality improvement efforts.

Two of the hospitals using CCRS have the most experience with the system. Hill Country Memorial Hospital in Fredericksburg, Texas, began using the system in October 2003 for all clinical staff except physicians. Debbye Wallace, Quality Management Executive Director of Quality and Community Services, cited three features of the system—its capacity to increase awareness of close calls, its anonymity, and its ease of use—as its strong points. The hospital has incorporated CCRS in its intranet site, but also makes it available to clinical staff in a paper-based format. Reports are developed based on close calls identified. Wallace reviews these reports and also forwards them to the appropriate manager or director for corrective action.

The University of Texas (UT) Health Center at Tyler has been using the system for about two years. All clinical staff use the system, with the heaviest use by pharmacists and nurses. Tom Belt, MD, Medical Director for Clinical Operations for the hospital, commended three aspects of the system—the flexibility of reporting (through either a computer- or paper-based system), the relative ease of making a report, and reassurances about anonymity. Reports are coordinated through the Health Center's patient safety officer, who is responsible for assuring any follow-up action.

Hill Country Memorial is an 84-bed nonprofit private community hospital serving an eight-county area centered in Fredericksburg, Texas. UT Health Center at Tyler has slightly over 100 beds and is one of six health care components of the UT System; it is a teaching hospital with two residency programs.

Impact Case Study Identifier: 
AHRQ Product(s): Research
Topics(s): Patient Safety
Geographic Location: New York, Texas
Implementer: Hill Country Memorial Hospital, University of Texas Health Center at Tyler
Date: 05/01/2006

Etchegaray JM, Thomas EJ, Geraci JM, et al. Differentiating close calls from errors: a multidisciplinary perspective. Journal of Patient Safety Sept. 2005; 1(3):133-7. (HS115440)

Page last reviewed October 2014