Implementation of systematic cross-checking between emergency department physicians resulted in a significant decrease in adverse events, according to the results of CHARMED, a multicenter superiority trial, published in JAMA Internal Medicine.

Medical errors and adverse events are a major cause of death in the United States. Emergency department physicians must make rapid decisions often based on minimal information. As a result, emergency departments are at high risk for the occurrence of medical errors and adverse events. The reported rate of errors in emergency departments runs as high as 10%.

To determine whether implementation of a system of cross-checking could reduce such errors, Yonathan Freund, MD, PhD, of Service d’Accueil des Urgences, Hôpital Pitié-Salpêtrière, in Paris, France, and colleagues conducted a cluster crossover trial that analyzed a random sample of 14 adult patients per day during 2 10-day periods in 6 emergency departments across France. The study randomly assigned 1680 patients to standard care or systematic cross-checking between emergency department physicians, 3 times a day, with a brief presentation of one physician’s case to another and subsequent feedback from the second physician. The primary outcome was medical errors in the emergency department. This was characterized as an adverse event that was either a near miss or a serious adverse event.

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Among the 1680 patients, 8.6% had an adverse event. A total of 54 adverse events occurred in the 840 patients (6.4%) in the cross-check group and 90 events occurred in the 840 patients (10.7%) in the standard care group, for a relative risk reduction (RRR) of 40%. The absolute risk reduction (ARR) was 4.3%, and the number needed to treat (NNT) was 24. Although there was a significant reduction in the rate of near misses (RRR, 47%; ARR, 2.7%; NNT, 37), the reduction in the rate of preventable serious adverse events was not significant (RRR, 29%; ARR, 1.2%; NNT, 83).

The authors noted a number of limitations. They were not able to determine that the systematic cross-checking benefit was the result of the intervention, nor did they account for potential informal cross-checking that might have taken place between physicians in the control group. Furthermore, as the physicians in the 2 periods were not identified by name, it is possible that different physicians may have participated in the 2 crossover sessions and that they may have different baseline levels of risk for medical errors.

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The authors note that while the implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, this was primarily the result of a reduction in near misses. The study was underpowered to identify a significant effect on the rate of preventable adverse events.


Freund Y Goulet H, Leblanc J, et al. Effect of systematic physician cross-checking on reducing adverse events in the emergency department. The CHARMED cluster randomized trial. JAMA Intern Med. 2018;178(6):812-819.