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Redmond S, Barwise A, Zornes S, Dong Y, Herasevich S, Pinevich Y, Soleimani J, LeMahieu A, Leppin A, Pickering B. Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders. Health Serv Insights 2022; 15:11786329221123540. [PMID: 36119635 PMCID: PMC9476244 DOI: 10.1177/11786329221123540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.
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Affiliation(s)
- Sarah Redmond
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Zornes
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN, USA
| | - Aaron Leppin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Knowledge and Evaluation Research Unit (KER), Mayo Clinic, Rochester, MN, USA
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Williams KL, Renouf TS, Dubrowski A. Pitfalls in Emergency Medicine: Survey-Based Identification of Learning Objectives for Targeted Simulation Curricula by Emergency Department Staff. Cureus 2020; 12:e11965. [PMID: 33425541 PMCID: PMC7790324 DOI: 10.7759/cureus.11965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The emergency department is a complex practice environment into which numerous factors may introduce both human and system error. Emergency physicians have to assemble and manage multidisciplinary teams with a moment's notice to manage critically ill patients. The EM training programs across Canada are diverse with considerable variation among programs. Acquisition of both high acuity low occurrence (HALO) and crisis resource management (CRM) skills are crucial to the development of proficient emergency room physicians. Physicians and allied health workers were surveyed to identify potential causes of error in local emergency departments and to find simulation-driven solutions. METHODS An anonymous survey was prepared to evaluate potential pitfalls of emergency care in St. John's, NL, Canada. It was distributed electronically to 108 medical staff, including physicians, nurses, and postgraduate year three (PGY3) residents. Respondents were asked about their experience with simulation education, and whether or not they feel that there is an opportunity for it in postgraduate emergency medicine training. RESULTS The response rate was 30%. Communication - with the emergency department team, consulting services, and patients - was identified as a potential topic for simulation, along with interruptions. Burnout, busy department, departmental crowding, end of shift handover, and incomplete/missing patient medical history were identified as topics that should be included in the emergency medicine curriculum. Following a review with the simulation expert panel, it was determined that end of shift handover could also be incorporated as a simulation in the existing curriculum. DISCUSSION This survey looked at pitfalls in emergency medicine through a CRM lens. Six pitfalls were identified as important for patient safety, but not best addressed with simulation. These could be incorporated into the half-day curriculum as didactic lectures. Four important patient safety pitfalls were identified that could potentially be addressed with simulation and incorporated in the existing emergency medicine simulation curriculum.
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Affiliation(s)
- Kerry-Lynn Williams
- Family Medicine, Memorial University of Newfoundland, Happy Valley-Goose Bay, CAN
| | - Tia S Renouf
- Emergency Medicine, Memorial University of Newfoundland, St. John's, CAN
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Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AND, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J 2015; 33:253-9. [PMID: 26531859 DOI: 10.1136/emermed-2015-204754] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 09/05/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Diagnostic errors in the emergency department (ED) are harmful and costly. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns. DESIGN We conducted a retrospective chart review of ED patients >18 years at an urban academic hospital. A computerised 'trigger' algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and (2) had a return ED visit within 10 days that led to a hospitalisation. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available during the first ED visit, regardless of patient harm, and included errors that involved both ED and non-ED providers. Errors were determined by two independent record reviewers followed by team consensus in cases of disagreement. RESULTS Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient-provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results). The most frequently missed diagnoses were gallbladder pathology (n=10) and urinary infections (n=5). CONCLUSIONS Diagnostic process breakdowns in ED patients with abdominal pain most commonly involved history-taking, ordering insufficient tests in the patient-provider encounter and problems with follow-up of abnormal test results.
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Affiliation(s)
- Laura Medford-Davis
- Department of Emergency Medicine, Robert Wood Johnson Foundation Clinical Scholars, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Park
- Section of Emergency Medicine, Baylor College of Medicine and Harris Health System, Ben Taub General Hospital Emergency Center, Houston, Texas, USA
| | - Gil Shlamovitz
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - James Suliburk
- Michael E DeBakey Department of Surgery, Baylor College of Medicine and Harris Health System, Houston, Texas, USA
| | - Ashley N D Meyer
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Nishijima DK, Dinh T, May L, Yadav K, Gaddis GM, Cone DC. Quantifying federal funding and scholarly output related to the academic emergency medicine consensus conferences. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:176-181. [PMID: 24280853 PMCID: PMC4018650 DOI: 10.1097/acm.0000000000000073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE Every year since 2000, Academic Emergency Medicine (AEM) has presented a one-day consensus conference to generate a research agenda for advancement of a scientific topic. One of the 12 annual issues of AEM is reserved for the proceedings of these conferences. The purpose of this study was to measure academic productivity of these conferences by evaluating subsequent federal research funding received by authors of conference manuscripts and calculating citation counts of conference papers. METHOD This was a cross-sectional study. In 2012, the NIH RePORTER system was searched to identify subsequent federal funding obtained by authors of the consensus conference issues from 2000 to 2010. Funded projects were coded as related or unrelated to conference topic. Citation counts for all conference manuscripts were quantified using Scopus and Google Scholar. Simple descriptive statistics were reported. RESULTS Eight hundred fifty-two individual authors contributed to 280 papers published in the 11 consensus conference issues. One hundred thirty-seven authors (16%) obtained funding for 318 projects. A median of 22 topic-related projects per conference (range 10-97) accounted for a median of $20,488,331 per conference (range $7,779,512 to $122,918,205). The average (± SD) number of citations per paper was 15.7 ± 20.5 in Scopus and 23.7 ± 32.6 in Google Scholar. CONCLUSIONS The authors of consensus conference manuscripts obtained significant federal grant support for follow-up research related to conference themes. In addition, the manuscripts generated by these conferences were frequently cited. Conferences devoted to research agenda development appear to be an academically worthwhile endeavor.
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Affiliation(s)
- Daniel K Nishijima
- Dr. Nishijima is assistant professor, Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California. Ms. Dinh is research coordinator, Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California. Dr. May is assistant professor and associate director of clinical research, Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC. Dr. Yadav is assistant professor and clinical research fellowship director, Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC. Dr. Gaddis is St. Luke's/Missouri Endowed Chair for Emergency Medicine and professor of emergency medicine, University of Missouri-Kansas City School of Medicine. Dr. Cone is professor and EMS section chief, Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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Patterson PD, Pfeiffer AJ, Lave JR, Weaver MD, Abebe K, Krackhardt D, Arnold RM, Yealy DM. How familiar are clinician teammates in the emergency department? Emerg Med J 2013; 32:258-62. [PMID: 24351519 DOI: 10.1136/emermed-2013-203199] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Lack of familiarity between teammates is linked to worsened safety in high risk settings. The emergency department (ED) is a high risk healthcare setting where unfamiliar teams are created by diversity in clinician shift schedules and flexibility in clinician movement across the department. We sought to characterise familiarity between clinician teammates in one urban teaching hospital ED over a 22 week study period. METHODS We used a retrospective study design of shift scheduling data to calculate the mean weekly hours of familiarity between teammates at the dyadic level, and the proportion of clinicians with a minimum of 2, 5, 10 and 20 h of familiarity at any given hour during the study period. RESULTS Mean weekly hours of familiarity between ED clinician dyads was 2 h (SD 1.5). At any given hour over the study period, the proportions of clinicians with a minimum of 2, 5, 10 and 20 h of familiarity were 80%, 51%, 27% and 0.8%, respectively. CONCLUSIONS In our study, few clinicians could be described as having a high level of familiarity with teammates. The limited familiarity between ED clinicians identified in this study may be a natural feature of ED care delivery in academic settings. We provide a template for measurement of ED team familiarity.
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Affiliation(s)
- P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony J Pfeiffer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Judith R Lave
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Weaver
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kaleab Abebe
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Krackhardt
- David A Tepper School of Business, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Division of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ergonomie participative aux urgences — Méthode d’implantation de changements. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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An unexpected diagnosis: simulation reveals unanticipated deficiencies in resident physician dysrhythmia knowledge. Simul Healthc 2010; 5:21-3. [PMID: 20383086 DOI: 10.1097/sih.0b013e3181b2c526] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Decision support tools are an important adjunct to medical resuscitation. We initiated a study comparing the use of the traditional code book method versus a computerized decision support system. However, appropriate use of the tools requires correct initial recognition of the dysrhythmia. Using simulation, numerous deficiencies were revealed regarding resident physician dysrhythmia knowledge. Most importantly, the rate of incorrect dysrhythmia recognition required discontinuation of the initial study, reorganization, and implementation of a modified study to achieve the study purpose.
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Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med 2010; 28:304-9. [PMID: 20223387 DOI: 10.1016/j.ajem.2008.12.014] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists. METHODS We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves. RESULTS A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's rho = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day. CONCLUSIONS We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.
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Affiliation(s)
- Erik B Kulstad
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, IL 60453, USA.
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Meisel ZF, Hargarten S, Vernick J. Addressing Prehospital Patient Safety Using the Science of Injury Prevention andControl. PREHOSP EMERG CARE 2009; 12:411-6. [DOI: 10.1080/10903120802290851] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Levin S, Aronsky D, Hemphill R, Han J, Slagle J, France DJ. Shifting Toward Balance: Measuring the Distribution of Workload Among Emergency Physician Teams. Ann Emerg Med 2007; 50:419-23. [PMID: 17559969 DOI: 10.1016/j.annemergmed.2007.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Revised: 03/14/2007] [Accepted: 04/06/2007] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The objective of this investigation is to determine time-dependent workload patterns for emergency department (ED) physician teams across work shifts. A secondary aim was to demonstrate how ED demand patterns and the timing of shift changes influence the balance of workload among a physician team. METHODS Operational measurements of an adult ED were collected from a clinical information system to characterize physician workload patterns during all current work shifts. Plots of patient load versus time were developed for each physician shift, in which patient load was defined as the number of patients a physician simultaneously managed at a point in time. Patient-load curves for each shift were superimposed during 24 hours to display how patient load was distributed among a team of physicians. RESULTS Resident shift changes during daily peak occupancy periods caused patient load imbalances so that residents on a particular shift consistently managed a disproportionate number of patients (mean 9.4 patients; 95% confidence interval [CI] 6.7 to 12.1 patients) compared with other residents on duty (mean 3.4 patients; 95% CI 2.1 to 4.7 patients). CONCLUSION Physician patient load patterns and ED demand patterns should be taken into consideration when physician shift times are scheduled so that patient load may be balanced among a team. Real-time monitoring of physician patient load may reduce stress and prevent physicians from exceeding their safe capacity for workload.
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Affiliation(s)
- Scott Levin
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, TN, USA.
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Wright SW, Trott A, Lindsell CJ, Smith C, Gibler WB. Evidence-based emergency medicine. Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report. Ann Emerg Med 2007; 51:80-6, 86.e1-8. [PMID: 17719134 DOI: 10.1016/j.annemergmed.2007.04.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Revised: 03/30/2007] [Accepted: 04/09/2007] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE The Institute of Medicine, through its landmark report concerning errors in medicine, suggests that standardization of practice through systematic development and implementation of evidence-based clinical pathways is an effective way of reducing errors in emergency systems. The specialty of emergency medicine is well positioned to develop a complete system of innovative quality improvement, incorporating best practice guidelines with performance measures and practitioner feedback mechanisms to reduce errors and therefore improve quality of care. This article reviews the construction, ongoing development, and initial impact of such a system at a large, urban, university teaching hospital and at 2 affiliated community hospitals. METHODS The Committee for Procedural Quality and Evidence-Based Practice was formed within the Department of Emergency Medicine to establish evidence-based guidelines for nursing and provider care. The committee measures the effect of such guidelines, along with other quality measures, through pre- and postguideline patient care medical record audits. These measures are fed back to the providers in a provider-specific, peer-matched "scorecard." RESULTS The Committee for Procedural Quality and Evidence-Based Practice affects practice and performance within our department. Multiple physician and nursing guidelines have been developed and put into use. Using asthma as an example, time to first nebulizer treatment and time to disposition from the emergency department decreased. Initial therapeutic agent changed and documentation improved. CONCLUSION A comprehensive, guideline-driven, evidence-based approach to clinical practice is feasible within the structure of a department of emergency medicine. High-level departmental support with dedicated personnel is necessary for the success of such a system. Internet site development (available at http://www.CPQE.com) for product storage has proven valuable. Patient care has been improved in several ways; however, consistent and complete change in provider behavior remains elusive. Physician scorecards may play a role in altering these phenomena. Emergency medicine can play a leadership role in the development of quality improvement, error reduction, and pay-for-performance systems.
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Affiliation(s)
- Stewart W Wright
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45267-0769, USA.
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Barata IA, Benjamin LS, Mace SE, Herman MI, Goldman RD. Pediatric patient safety in the prehospital/emergency department setting. Pediatr Emerg Care 2007; 23:412-8. [PMID: 17572530 DOI: 10.1097/01.pec.0000278393.32752.9f] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.
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Affiliation(s)
- Isabel A Barata
- Department of Emergency Medicine, New York University School of Medicine, North Shore University Hospital, Manhasset, NY 11030, USA.
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Forster AJ, Rose NGW, van Walraven C, Stiell I. Adverse events following an emergency department visit. Qual Saf Health Care 2007; 16:17-22. [PMID: 17301197 PMCID: PMC2464922 DOI: 10.1136/qshc.2005.017384] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Many studies demonstrate a high rate of treatment-related adverse outcomes or adverse events. No studies have prospectively evaluated adverse events in patients discharged home from the emergency department (ED). OBJECTIVE To describe the types of adverse events in patients discharged home from an ED. PATIENTS PATIENTS who were sent home directly from the ED of an urban, academic teaching hospital in Ottawa, Canada. METHODS Patient records were reviewed to identify demographic and medical history information. Two weeks following the ED visit, patients completed a standard telephone interview to record post ED visit outcomes. Two physicians reviewed outcomes to identify all adverse events and their cause. RESULTS Follow-up was complete for 399 of 408 enrolled patients. The median age was 49 years (interquartile range 36-68) and 50% were male. The most common diagnosis was "chest pain", occurring in 74 patients (18%), followed by "bone and joint disorders" in 55 patients (14%). 24 patients experienced an adverse event (incidence 6% (95% CI 4% to 9%)), of which 17 were preventable (incidence 4% (95% CI 3% to 7%)). Five of the unpreventable adverse events were medication side effects and two were minor, procedure-related complications. Of all 24 adverse events, 15 (63%; 95% CI 43 to 79%) led to an additional ED visit or a hospitalisation. Preventable adverse events occurred in 5 of 78 chest pain patients (incidence 6% (95% CI 3% to 14%)). CONCLUSION Most adverse events occurring following an ED visit are preventable and often relate to diagnostic or management errors.
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Affiliation(s)
- Alan J Forster
- Ottawa Health Research Institute--Clinical Epidemiology Program, Ottawa, Ontario, Canada.
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Hendrie J, Sammartino L, Silvapulle MJ, Braitberg G. Experience in adverse events detection in an emergency department: Nature of events. Emerg Med Australas 2007; 19:9-15. [PMID: 17305655 DOI: 10.1111/j.1742-6723.2006.00897.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The study was performed to determine the nature of adverse events in an ED. METHODS The methodology has been described in the accompanying paper. Two by two tables were analysed using the two-tailed Fisher's exact test. A P-value of < or =0.05 was considered significant. Statistical analysis was performed using MINITAB. RESULTS One hundred and ninety-four events were detected, from a sample of 3222 patients. Except where specified, events with management causation < or =3 were excluded. This excluded 24 events (12.4%) leaving 170 for analysis. Errors of commission occurred in 55% and omission in 45%. Errors of commission were significantly associated with prior events, errors of omission with ED events (P < or = 0.0001, respectively). The most common cause of events was drug reactions. 1.35% had a Naranjo score > or = 1, 0.54% > or = 4. Prior events were significantly associated with adverse drug reactions (P < or = 0.0001). Drug reactions were associated with a lower preventability score (P < or = 0.0001). Diagnostic issues were present in 1.2%. All three categories, that is diagnosis not considered, diagnosis within the differential and seriousness not appreciated were associated preventability > or =4 (P < or = 0.0001, P < or = 0.02 and P < or = 0.004, respectively). Diagnostic problems were significantly associated with ED events (P < or = 0.0001). CONCLUSION In conclusion, the data demonstrate that events fall into two sets: prior events which are associated with errors of commission, drug reactions and lower preventability; and ED events which are associated with errors of omission, diagnostic issues and high preventability.
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Affiliation(s)
- James Hendrie
- Emergency Department, Austin Health, Victoria, Australia.
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Henneman EA, Blank FSJ, Gattasso S, Williamson K, Henneman PL. Testing a classification model for emergency department errors. J Adv Nurs 2006; 55:90-9. [PMID: 16768743 DOI: 10.1111/j.1365-2648.2006.03878.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM This paper presents an evaluation of the Eindhoven Classification Model for categorizing healthcare errors. BACKGROUND The ability to decrease healthcare errors will depend on an understanding of the types and patterns of error that occur in various settings. Research addressing the systematic classification of error is in its infancy. METHODS The sample for this study was two existing sets of healthcare error reports obtained from the emergency department of a regional trauma center. Study data were collected in the summer of 2001 and 2002. The errors in these reports were categorized using a coding tool based on the Eindhoven Classification Model. In addition to testing for inter-rater reliability, the classification model was also evaluated for the number of unclassifiable errors and of categories never selected by the raters (not useful to the error classification model). RESULTS Our findings of poor inter-rater reliability, large numbers of unclassifiable errors and categories not selected, suggest that the Eindhoven Classification Model, in its current form, cannot be applied to categorizing healthcare errors in an emergency department setting. CONCLUSIONS Further study is needed to develop and test error categorization models for use in emergency departments and other healthcare settings.
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Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2006; 49:196-205. [PMID: 16997424 DOI: 10.1016/j.annemergmed.2006.06.035] [Citation(s) in RCA: 281] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2005] [Revised: 06/07/2006] [Accepted: 06/26/2006] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVES Diagnostic errors in the emergency department (ED) are an important patient safety concern, but little is known about their cause. We identify types and causes of missed or delayed diagnoses in the ED. METHODS This is a review of 122 closed malpractice claims from 4 liability insurers in which patients had alleged a missed or delayed diagnosis in the ED. Trained physician reviewers examined the litigation files and the associated medical records to determine whether an adverse outcome because of a missed diagnosis had occurred, what breakdowns were involved in the missed diagnosis, and what factors contributed to it. Main outcome measures were missed diagnoses, process breakdowns, and contributing factors. RESULTS A total of 79 claims (65%) involved missed ED diagnoses that harmed patients. Forty-eight percent of these missed diagnoses were associated with serious harm, and 39% resulted in death. The leading breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (58% of errors), failure to perform an adequate medical history or physical examination (42%), incorrect interpretation of a diagnostic test (37%), and failure to order an appropriate consultation (33%). The leading contributing factors to the missed diagnoses were cognitive factors (96%), patient-related factors (34%), lack of appropriate supervision (30%), inadequate handoffs (24%), and excessive workload (23%). The median numbers of process breakdowns and contributing factors per missed diagnosis were 2 and 3, respectively. CONCLUSION Missed diagnoses in the ED have a complex cause. They are typically the result of multiple breakdowns in the diagnostic process and several contributing factors.
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Affiliation(s)
- Allen Kachalia
- Division of General Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Levin S, France DJ, Hemphill R, Jones I, Chen KY, Rickard D, Makowski R, Aronsky D. Tracking workload in the emergency department. HUMAN FACTORS 2006; 48:526-39. [PMID: 17063967 DOI: 10.1518/001872006778606903] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The primary objective of this study was to create a methodology for measuring transient levels of physician workload in a live emergency department (ED) environment. BACKGROUND Characterizing, defining, and measuring aspects of this interrupt-driven work environment represent the preliminary steps in addressing impending issues concerning ED overcrowding, efficiency, and patient and provider safety. METHODS A time-motion task analysis was conducted. Twenty emergency medicine (EM) physicians were observed for 180-min intervals in an ED of an academic medical center. Near continuous workload measures were developed and used to track changing workload levels in time. These measures were taken from subjective, objective, and physiological perspectives. The NASA-Task Load Index was administered to each physician after observational sessions to measure subjective workload. Physiological measurements were taken throughout the duration of the observation to measure stress response. Additional information concerning physicians' patient quantity and patient complexity was extracted from the ED information system. RESULTS Graphical workload profiles were created by combining observational and subjective data with system state data. Methodologies behind the creation of workload profiles are discussed, the workload profiles are compared, and quantitative and qualitative analyses are conducted. CONCLUSION Using human factors methods to measure workload in a setting such as the ED proves to be challenging but has relevant application in improving the efficiency and safety of EM. APPLICATION Techniques implemented in this research are applicable in managing ED staff and real-time monitoring of physician workload.
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Affiliation(s)
- Scott Levin
- Vanderbilt University, Department of Biomedical Engineering, 2044 Convent Pl., Nashville, TN 37212, USA.
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18
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Fordyce J, Blank FSJ, Pekow P, Smithline HA, Ritter G, Gehlbach S, Benjamin E, Henneman PL. Errors in a busy emergency department. Ann Emerg Med 2003; 42:324-33. [PMID: 12944883 DOI: 10.1016/s0196-0644(03)00398-6] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE We describe errors occurring in a busy ED. METHODS This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets. RESULTS One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P <.0001) and more likely to have higher visit level intensity (P <.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome. CONCLUSION Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.
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Affiliation(s)
- James Fordyce
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA 01199, USA
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19
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Phelps M, Lubavin B. A beginner's guide to research in emergency medicine. J Emerg Med 2001; 21:211-2. [PMID: 11489415 DOI: 10.1016/s0736-4679(01)00369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- M Phelps
- College of Medicine, University of California at Irvine, USA
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