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ED teamwork failures and major cognitive errors occurred in each of the cases of permanent harm or death, and in two of these cases, hospital teamwork failures also occurred.


Contributing to the identified PSIs, systems failures were almost twice as common as practitioner-based errors. Only in one case did harm result from a practitioner-based error in isolation. These findings suggest that systems failures within the ED work environment contribute more significantly to PSIs and patient harm.

To date, investigations of PSIs in the ED setting have been fairly limited in number despite the importance and urgency of improving our understanding of PSIs. Contributing to this relative lack of data is the fact that no clear consensus on optimal methodologies in this area of research exists.

Of the few studies that do exist in EM including this one, all have highly disparate methodologies [ 8 , 9 , 11 — 13 ]. Because of their varied study designs, the ED PSI investigations have unique potential advantage and disadvantage profiles. For example, the National Emergency Department Safety Study was a large multi-center study that identified PSIs by structured chart review but only focused on a limited number of medical conditions: myocardial infarction, asthma exacerbation, and joint dislocation involving procedural sedation [ 8 , 12 ].

Another study by Fordyce et al. Smith et al. Finally, the only peer review-based investigation other than the present study, Berk et al. In contrast to the aforementioned studies, the unique strengths of the present study design included a structured, non-punitive peer review process that incorporated feedback from the practitioner s involved in the care in question, allowing for first-person accounts of the case under review.


Lastly, the present study examined potential PSIs occurring over an extended two-year time frame and was not limited by diagnosis-based inclusion criteria. Given this unique design advantage profile as well as some potential limitations discussed below , the present investigation complements the existing, limited body of original investigations of ED PSIs. Our results are consistent with those prior studies that have implicated work systems as being intimately involved in ED PSIs. For instance, other investigators have stated that ED systems must be changed in order to lower the incidence of errors [ 11 ], and Camargo et al.

In aggregate, ED PSI studies, including the present investigation, provide a significant, growing body of evidence supporting those who have argued that heightened focus should be placed on the work environment and other factors that contribute to error rather than on the error itself [ 14 , 16 , 17 ]. Anecdotally, a few of these reports were submitted by healthcare providers that were not aware of all of the facts of a case at the time that they submitted their incident report, but the majority of the reports that did not progress past the initial screening involved complaints submitted by patients and families.

Data from previous investigations have suggested that patient and family concerns often are related to incomplete or delayed relief in symptoms, suboptimal practitioner communication, or billing related to their medical services [ 6 , 18 , 19 ].

Patient Safety in Emergency Medicine - Google книги

Our anecdotal experience matched these previous reports. While such feedback was still highly valued for its potential to improve the overall patient experience and was acted upon via other mechanisms within the department , it did not meet criteria to progress to peer review committee analysis because a safety incident had not occurred. The present study has several design strengths including the highly structured peer review process and the extended study time-period, however, it also has potential limitations that must be considered when interpreting the results.

First, any peer review process necessarily requires human interpretation and as such may be prone to bias [ 17 , 20 , 21 ]. Several measures were designed into the peer review process to reduce the potential for bias, but it was unlikely that all bias was eliminated. A second potential limitation was the fact that the preliminary screening was performed by a single reviewer. While not ideal, this format was necessary due to practical considerations. To minimize potential accuracy or bias limitations inherent in single-reviewer screening, the chosen preliminary reviewer had greater than ten years of professional experience in peer review as well as health-care quality management in general.

In addition, the preliminary review process was designed to be more inclusive to minimize the potential for missing any true PSIs. It is not possible to determine definitively if this approach was effective in this regard, however the finding that 36 cases A third potential limitation of the present study was that the review process only identified harm having occurred if a causal relationship between a PSI and patient harm was definitive. This likely increased the false negative rate for harm causality. A final potential criticism of the present study design could be that it may have missed a significant number of PSIs because under-capture of PSIs is known to occur with passive incident reporting systems in inpatient settings [ 22 — 24 ].

Theoretically, this phenomenon likely also exists in the ED setting, but the extent to which it occurs in the ED has yet to be studied objectively. Some have suggested automatic reviews of hour ED returns, deaths within a certain time frame of admission from the ED, and ED deaths as additional potential sources for improved PSI capture in the ED [ 13 , 25 ]. However, the effectiveness of these methods have not been studied, so the extent to which the results may have been affected by not including them in the study methodology is unclear. Of note, ED deaths were automatically reviewed via a separate process within the institution.

Over the two-year period of this study, this separate ED death review process found only two cases having concerns for PSIs, and both in fact were captured independently by the peer review process described in this investigation. This may provide some support toward automatic ED death reviews not being of additional benefit.

We are aware of no specific data to support the following hypothesis, but it may be possible that the phenomenon of under-reporting of incidents may not be as pronounced in the ED as other healthcare settings. Nearly all patient care occurring in the ED results in a hand-off to an inpatient or outpatient team. Those teams may be more likely to report incidents both because PSIs may become more apparent with the passage of time and because there may be fewer perceived disincentives to reporting if the reporter or their departmental colleagues were not primarily responsible for the care in question.

While it is not possible to determine the extent of under-reporting of incidents that occurred during this study, for the reasons outlined above, we believe that the effect may not have been as significant as some may theorize. In addition, while under-reporting may have resulted in the total number of identified PSIs being low, we have no reason to suspect that the phenomenon would bias the proportion of systems failures versus practitioner based-errors, although we acknowledge that it remains possible.

The results of this investigation reveal that systems failures lead to PSIs and patient harm more frequently than practitioner-based errors in the ED. These findings suggest that to effectively reduce PSIs and patient harm, systems failure prevention should be a priority within ED quality programs. He has also served previously as a Vice President of Quality and Patient Safety in a large, urban, teaching hospital. CED had extensive original research publication experience in multiple areas of Emergency Medicine and an interest in quality improvement.

Chantler C: The role and education of doctors in the delivery of health care. Groves EW: A plea for the uniform registration of operation results. Br Med J. Codman EA: The product of a hospital. Surg Gynecol Obstet. World Health Organization: Conceptual framework for the international classification of patient safety. Schenkel S: Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med. Intern Emerg Med. J Grad Med Educ. Eur J Emerg Med. Ann Emerg Med. Leape LL: Errors in medicine. Clin Chim Acta. Cosby KS: A framework for classifying factors that contribute to error in the emergency department.

Freedman S: Best practices for enhancing quality. Pat Safety Qual Healthcare. Peters PG: Twenty years of evidence on the outcomes of malpractice claims. Clin Orthop Relat Res. Hospital incident reporting systems do not capture most patient harm. Johnson CW: How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events. Qual Saf Health Care.

Penn Presbyterian Medical Center’s Emergency Medicine Department: Patient Guide

Olsen S, Neale G, Schwab K, Psaila B, Patel T, Chapman EJ, Vincent C: Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Emerg Med J. Download references. Correspondence to Martin A Reznek. ZKJ and MAR drafted the manuscript, and all authors contributed substantially to its content and finalization.

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All authors read and approved the final manuscript. Reprints and Permissions. Search all BMC articles Search. Overcrowding is associated with increased number of medication errors [ 37 ]. Finally, and not unexpectedly, overcrowding leads to increased length of stay and delay to treatment, even in patients with ESI 2 triage scores [ 38 ].

Within the parameters of decreasing overcrowding, the problem is often approached from an input-throughput-output model, with solutions to decrease the number of patients presenting to EDs, decreasing total time spent in the ED, and facilitating either transfer to other locales within the hospital or facilitating outpatient follow-up. The Agency for Healthcare Research and Quality recommends forming a Patient Flow Team consisting of including a team leader day-to-day leader , senior hospital leader e. Having input from multiple staff with unique insight into the delays specific to their specialty as well as ways that delays may be approached can lead to more effective change.

Emergency department (ED) patient safety checklist

As well, having individuals involved in the clinical arena can improve the team approach to problem solving and implementation of new systems. Prior to initiating solutions, management teams must know their own baseline benchmarks, must identify goals and strategies to decrease crowding in their unique environment, must plan the approach to implementation with estimates of time and costs of implementation, and then must remeasure after implementation to determine how they have approached their benchmark.

With the introduction of electronic health record systems, such measures should become increasingly effortless to obtain and track over time. The data that are generated need to be rapidly disseminated in a transparent manner to reinforce the values of change or to justify reworking the solutions. Initiating processes to decrease patient presentations to the ED have limited effectiveness in reducing ED crowding.

In a study performed in Ontario hospitals, low acuity patients were found to have a negligible effect on ED length of stay [ 41 ]. Although ambulance diversion is frequently employed in the setting of ED crowding, a review of ambulance diversion from found no papers specifically addressing the effect of ambulance diversion on ED crowding [ 22 ]. Computer-generated simulation models have suggested that ambulance diversion will have little effect on an already overcrowded ED [ 42 ].

One such model suggested that for every percentage point increase in the time spent on ambulance diversion, ED waiting room time would decrease by 2 min [ 43 ]. Further evidence suggesting that ambulance diversion is not an effective method to decrease ED crowding is provided by the state of Massachusetts, who banned ambulance diversion statewide, and saw a small drop in ED LOS [ 44 ]. Improving ED front-end operations has been seen as a potential way to increase ED patient throughput. A review of literature found articles that supported that bedside registration decreases patient waiting time, total ED LOS, and the number of patients who leave without being seen [ 45 ].

The authors point out that a number of the studies that they reviewed are fraught with methodological flaws and include only single centers, limiting the conclusions that can be drawn from these studies [ 45 ]. As ED wait times increase with overcrowding, utilizing the patient waiting time for processes that would otherwise take a long time becomes important.

Groups have proposed initiating evaluations or treatments for standard problems from the waiting room [ 46 ]. Initiating lab testing from triage has two potential effects. Additionally, performing labs from triage could potentially identify patients requiring more immediate attention if there is a way to flag critical values to a responsible provider [ 48 ]. A systemic review of triage nurses ordering radiographs has demonstrated nearly a min decrease in patient LOS with implementation of triage nursing orders [ 49 ].

Studies have suggested that having an advanced practitioner or a physician in triage may reduce the ED LOS and rates of leaving without being seen [ 45 , 50 ]. Both of these studies occurred in Canada, however, where delivery care might be different than other settings, thus limiting their generalizability [ 51 , 52 ]. Two other randomized controlled trials demonstrated no affect of physician in triage on LOS [ 50 ]. In cases where there are patients in the ED waiting for providers long ED bed placement to provider evaluation times , adding providers can decrease patient TATs, effectively decreasing crowding.

In a study in a Swiss ED, adding a provider to a busy evening shift decreased the average LOS of discharged patients by 35 min. Similarly, if it is determined that patients are awaiting nursing care in the ED, improving nursing ratios may decrease TATs and ED crowding.

Additionally, a pre-post observational study performed in conjunction with nearly doubling an ED's capacity found that this had no affect on the time of ambulance diversion or left without being seen [ 55 ]. Introducing a system with a rapid admission policy whereby stable ED patients are admitted to the hospital without having a prior ED evaluation by the admitting staff and with incomplete diagnostic testing, minimally decreased ED LOS 10 min but decreased weekly ambulance diversion time by nearly 3 h [ 56 ].

The single factor that has been demonstrated to be the most effective at reducing ED crowding is to reduce ED boarding of admitted patients and facilitate movement of ED patients to inpatient beds [ 19 , 57 — 61 ]. Therefore, any attempt to focus on improving ED throughput should focus on attempts to minimize ED boarding and facilitate inpatient admission.

Patient Safety in Emergency Care Transitions

Because ED crowding has been associated with holding in the ED while awaiting inpatient bed assignment, an obvious mitigator would be to increase inpatient beds. Likewise, increasing beds outside of the ED with the formation of observation or short stay units has been demonstrated to decrease crowding and decrease ambulance diversion [ 62 ]. Another strategy that has been suggested is the boarding of patients in inpatient hallways as opposed to the ED.

Although effects on hospital crowding have not been documented, survey studies have demonstrated that patients have a preference for inpatient hallway boarding to ED boarding [ 63 — 65 ]. Inpatient hospital process improvement, such as earlier hospital discharge, has been demonstrated to decrease overcrowding when the hospital nears full capacity. Improving time to hospital discharge by as little as 1 h has been demonstrated to have significant effect on crowding [ 66 ]. Toward this end, some have advocated that discharge from inpatient hospital beds should occur before 12 o'clock noon and impact on emergency department crowding should be studied before and after [ 67 ].

One health network has found that incentivizing housekeeping staff to more rapid inpatient bed turnover has led to significant decreases in ED waiting times and ambulance diversions [ 68 ]. Other systems issues that have been targeted for improving hospital flow include smoothing the elective surgical schedule [ 69 ]. Ultimately, there is no single fix that will improve the entire system. Rather, the implementation of multiple solutions Table 2 is required to decrease emergency department crowding. Careful scrutiny of the institution's existing processes and identification of specific areas of improvement is the first step to managing patient flow issues.

Beyond this, hospitals must buy in from both administration, nursing, physician, and ancillary staff, and must also be willing to make resource investments to improve patient flow. Implementation of best practice bundles like the Urgent Mattes Toolkit across health systems has demonstrated great successes but demonstrated no improvements in about a third of hospitals, because it is often difficult for smaller, nonteaching, rural hospitals to invest the resources in staff and infrastructure that are required to make change [ 70 , 71 ].

ED crowding is a reality in many EDs and is likely to persist at times despite implementation of all reasonable strategies to mitigate crowding. In these situations, it is important for all providers to be aware of the increased likelihood of potential errors and to mindfully employ mechanisms to avoid them. Delivery of quality care in the face of crowding can be challenging, but is not impossible.

The first step in quality care occurs with an adequate and accurate triage to identify those individuals who really cannot wait. The future of medicine may include the use of predictive biomarkers in addition to standard triage to identify patients at the highest risk of mortality [ 72 ]. At triage, interventions to initiate care like triage EKGs that are reviewed real time by a physicians, drawing of triage labs based on complaint to identify those with severe disease, and ordering of appropriate radiographs may improve delivery of quality care.

Likewise, analgesia for fractures, topical anesthetic for lacerations or anti-pyretics for fever could be protocolized to decrease time to effective therapies. As EDs become busier, the number of simultaneous tasks that need to be coordinated and tracked by staff increases. This cognitive workload can be lessened by the use of protocols, teamwork training to facilitate inter-provider assistance, and by the use of information technology solutions such as flagging abnormal results or communicating a patient's completed care tasks.

Existing safeguard mechanisms to appropriately identify patients by wrist bands prior to medication administration and test and procedure performance need to be strictly adhered to despite the time taken to complete these tasks. As departments become busier, interruptions increase which can lead to decreasing performance, so mechanisms to limit interruptions could be important to decreasing errors [ 73 ].

Although research priorities into patient safety have been developed, little literature exists regarding how interventions and specific processes affect safety [ 74 ]. Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers. Login to your personal dashboard for more detailed statistics on your publications.

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Edited by Michael S. We are IntechOpen, the world's leading publisher of Open Access books. Built by scientists, for scientists. Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals. Downloaded: Abstract Emergency department ED overcrowding is a recognized problem worldwide. Keywords emergency department overcrowding emergency department safety emergency department systems emergency department patient care emergency department throughput emergency department output. Case vignette A year-old man presented to the emergency department ED with abdominal pain.

Introduction Emergency department ED overcrowding is a recognized problem worldwide [ 1 , 2 ]. History of overcrowding The timing of ED overcrowding becoming a major issue in the US coincided with the closing of hospitals across the country, a decrease in the number of available inpatient hospital beds, and an increase in ED visits [ 8 ]. Health care system factors in overcrowding: output, input, and throughput It is always a failure of understanding to refer to ED overcrowding as an ED issue. The impact of overcrowding on patient care Numerous studies have demonstrated that ED overcrowding is harmful to patient care.

Measure name CMS effective date Head CT scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT scan interpretation within 45 min of arrival Troponin results for ED acute myocardial infarction AMI patients or chest pain patients with probable cardiac chest pain received within 60 min of arrival Median time to pain management for long bone fracture Patient left before being seen Door to diagnostic evaluation by a qualified medical professional Median time from ED arrival to ED departure for discharged ED patients Median time from ED arrival to ED departure for admitted ED patients Admit decision time to ED departure time for admitted patients Additional measures to track ED arrival to bed placement Disposition to departure Hours on diversion Time of inpatient bed assignment to bed placement Time of day of discharge Inpatient bed turnaround time patient discharge to bed readiness.

Measurements of emergency department crowding. Decreasing patient presentations to the ED Initiating processes to decrease patient presentations to the ED have limited effectiveness in reducing ED crowding. Improving emergency department patient throughput Improving ED front-end operations has been seen as a potential way to increase ED patient throughput. Facilitating the output from the emergency department The single factor that has been demonstrated to be the most effective at reducing ED crowding is to reduce ED boarding of admitted patients and facilitate movement of ED patients to inpatient beds [ 19 , 57 — 61 ].

Improved staffing Physicians Nurses Techs Registration Decreased process turnaround Triage Registration Diagnostic imaging Laboratory processes Specialist consultations Decreased care time Medication availability Stocking issues Time to completion of nursing tasks Workload balance among staff Physical space Hallway beds Observation units Flex beds Standardized resources Disease pathways Hospital dynamics Decreased OR scheduling variability Early hospital discharge Automated inpatient bed cycling Automated nursing report ED-inpatient bed transport Hallway boarding Reverse triage.

Process improvement opportunities to decrease emergency department crowding. Mechanisms to mitigate bad outcomes in the setting of overcrowding ED crowding is a reality in many EDs and is likely to persist at times despite implementation of all reasonable strategies to mitigate crowding. More Print chapter. How to cite and reference Link to this chapter Copy to clipboard. Firstenberg and Stanislaw P. Available from:. Over 21, IntechOpen readers like this topic Help us write another book on this subject and reach those readers Suggest a book topic Books open for submissions.

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