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    Original Investigation
    June 2018

    Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department: The CHARMED Cluster Randomized Trial

    Author Affiliations
    • 1Sorbonne Université, Paris, France
    • 2Emergency department, Hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
    • 3Plateforme de recherche clinique (URC-CRC-CRB), Hôpital Saint-Antoine, APHP, Paris, France
    • 4Emergency department, Hôpital Cochin, APHP, Paris, France
    • 5Emergency department, Hôpital Tenon, APHP, Paris, France
    • 6Emergency department, University Grenoble Alps, Hôpital Michallon, Grenoble, France
    • 7Emergency department, Hôpital Avicenne, APHP, Paris, France
    • 8Emergency department, Hôpital Lariboisière, APHP, Paris, France
    • 9Emergency department, Hôpital Européen Georges Pompidou, APHP, Paris, France
    • 10Emergency department, Hôpital Saint-Antoine, APHP, Paris, France
    • 11Emergency department, Barts Health NHS Trust, London, England.
    JAMA Intern Med. 2018;178(6):812-819. doi:10.1001/jamainternmed.2018.0607
    Key Points

    Question  Does the implementation of systematic physician cross-checking reduce the rate of adverse events in the emergency department?

    Findings  In this cluster randomized trial that included 1680 patients, the implementation of systematic cross-checking between physicians resulted in a significant relative risk reduction for adverse events. The rate of adverse events was 10.7% in the control group vs 6.4% in the cross-checking group.

    Meaning  Systematic physician cross-checking may be a key to reducing the high rate of adverse events in the emergency department.


    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.

    Trial Registration  ClinicalTrials.gov Identifier: NCT02356926