Introduction: Traditionally, surgical audit has identified and highlighted the incidence of adverse events complicating a patient's care. The airline industry has taken this concept a step further back by identifying and studying near misses, i.e. events that have the potential to do harm. We have applied this approach to patients with known or suspected bladder cancer.
Patients and methods: A prospective study was performed by two urology firms on all patients with known or suspected bladder cancer over a 3-week period. Patients presented to either a central (hub) hospital, or to an associated (spoke) hospital. Four stages in bladder cancer care were considered: (i) diagnostic or check flexible cystoscopy; (ii) admission to hospital prior to TURBT; (iii) peri-operative period; and (iv) first out-patient consultation. A separate proforma, comprising various aspects of management was used for each of these stages of care. If any one criterion was not met, the episode was recorded as a near miss. Near misses were classified as due to capacity limitations in the system, clerical error, equipment failure, clinical error and patient failure.
Results: A total of 115 completed episodes were recorded. A near miss was recorded in 65 (56.5%) of all episodes. Capacity limitations accounted for 54%, clinical error for 23%, clerical error for 16%, patient failure for 5% and equipment failure for 2% of all recorded near misses. Of particular note is that near misses relating to diagnosis were more common at the spoke hospital, delayed referral from GPs accounted for more than 25% of clinical error, diagnosis of 5 new bladder tumours was delayed and availability of upper tract imaging was a problem at all phases of patient management.
Conclusions: Near misses are very common in the management of patients with bladder cancer, and their identification should provide a useful framework for identifying potential areas for improvement in patient care.