A close call is an event that could have resulted in unwanted consequences but did not because, either by chance or through timely intervention, the event did not reach a patient. Other sources may refer to close calls as “near misses” or “good catches.”
Close calls allow pharmacy teams to recognize risks in their processes before they have an opportunity to impact patient safety. Importantly, pharmacy teams must also recognize the learning value of close calls and analyze them accordingly.
Mr. Jones arrives at the pharmacy to pick up his monthly blister packs. As John, the pharmacist, retrieves them from the pickup drawer, he recalls a recent telephone conversation with Mr. Jones’ family physician in which she discontinued Mr. Jones’ metoprolol due to hypotension. John quickly looks at the blister pack and, to his surprise, he notices that the metoprolol is still included. He advises Mr. Jones to sit down for a moment while he reviews his patient profile. After confirming that the medication indeed should have been discontinued, John quickly fixes the blister pack.
Reflecting on the circumstances, John recalls discontinuing the metoprolol in the pharmacy dispensing software; however, he didn’t realize at the time that his blister packs were already made and ready for pickup. The pharmacy’s policies and procedures do not outline a specific process for discontinuing medications for blister pack patients.
Documentation, analysis, and reporting of close calls is a mandatory component of ACP’s CQI+ program. Close calls must be documented, analyzed, and actioned in the same manner as practice incidents.
However, it can be difficult to identify when a close call has occurred, since many standard pharmacy processes (e.g., double checks, barcode scanning) are specifically designed to catch errors or otherwise mitigate incidents before they occur. Typically, errors detected through these processes would not be considered close calls. Instead, close calls are events detected outside of established, routine pharmacy processes.
Licensees must document site-specific policies and procedures to ensure close calls are identified and actioned appropriately. Use the following criteria1 to determine when a close call has occurred:
If the event meets any of these criteria, it must be documented, analyzed, actioned, and reported to the national database.
In the above example, at least two of the criteria were met. If Mr. Jones had inadvertently taken the metoprolol, he could have been at risk of a fall or other adverse outcomes. The close call also provides a learning opportunity for the pharmacy team, likely resulting in a new or updated process around discontinuations.
This close call must therefore be documented in the practice incident management platform, analyzed, and actioned. It must also be reported to the NIDR to share the learning opportunity with others across the country.