The Factor VIII Debate: An Auto-Cancelled Lab Near Miss

Near misses, medical errors with no appreciable resultant harm, often go undetected and underreported despite great emphasis on patient safety event reporting over the past two decades.1 Additionally, near misses are often not triggers for proactive institutional corrective action due to the widespread retroactive safety culture following more harmful or catastrophic safety events.2 At Thomas Jefferson University Hospital, all internal medicine first-year residents (PGY1s) participate in an immersive safety event review curriculum of near miss or low-harm safety events, previously described in the literature.3 The following details the event review findings and implemented health-system level changes following a trainee-led apparent cause analysis involving post-transfusion labs auto-cancelled by the electronic medical record without physician knowledge in a patient admitted to the hospital with active bleeding related to von Willebrand disease (vWD) requiring von Willebrand factor/factor VIII replacement therapy (Humate-P®).