Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Characterization of Emergency Department Quality Assurance Cases Seen Within a Midwestern United States Health System

BACKGROUND

Hospital quality-assurance (QA) processes, including peer-review committees, seek to identify high-risk areas.

PURPOSE

To characterize emergency department (ED) cases sent for QA review.

METHODS

A retrospective observational study was conducted of ED cases sent to a QA committee from November 2018 through July 2022 at three midwestern US hospitals. The QA records analyzed for these cases included the original incident report, case summary, and the committee determinations.

RESULTS

One hundred and forty-seven cases were reviewed by the ED QA Committee. The most frequent referrals came from physicians. Common diagnostic categories included infectious (21%), cardiac (16%), gastrointestinal (11%), and neurologic (10%) concerns. Of the cases, 51% were considered nonpreventable, 33% were potentially preventable, and 9% were preventable. Inpatient boarding in the ED was explicitly implicated as a contributing factor in 6% of case reports.

CONCLUSIONS

Peer physician reporting represent the largest referral source sent for review with the most frequent diagnostic categories, including infectious, cardiac, gastrointestinal, and neurological conditions. Preventable concerns were rare.

IMPLICATIONS

This study provides a better understanding of the referral sources, diagnostic categories, and committee determinations in ED quality concerns. These results can target future investigations into case reporting and patient safety.

Regular Medications in the Emergency Department Short Stay Unit (ReMedIES): Can Prescribing be Improved Without Increasing Resources?

Background: Hospital medication errors are frequent and may result in adverse events. Data on non-prescription of regular medications to emergency department short stay unit patients is lacking. In response to local reports of regular medication omissions, a multi-disciplinary team was tasked to introduce corrective emergency department (ED) process changes, but with no additional financing or resources. Aim: To reduce the rate of non-prescription of regular medications for patients admitted to the ED Short Stay Unit (SSU), through process change within existing resource constraints. Methods: A pre- and post-intervention observational study compared regular medication omission rates for patients admitted to the ED SSU. Included patients were those who usually took regular home medications at 08:00 or 20:00. Omissions were classified as clinically significant medications (CSMs) or non-clinically significant medications (non-CSMs). The intervention included reinforcement that the initially treating acute ED doctor was responsible for prescription completion, formal checking of prescription presence at SSU handover rounds, double-checking of prescription completeness by the overnight SSU lead nurse and junior doctor, and ED pharmacist medication reconciliation for those still identified as having regular medication non-prescription at 07:30. Results: For the 110 and 106 patients in the pre- and post-intervention periods, there was a non-significant reduction in the CSM omission rate of -11% (95% CI: -23 to 2), from 41% (95% CI: 32-50) to 30% (95% CI: 21-39). Conclusion: Non-prescription of regular CSMs for SSU patients was not significantly reduced by institution of work practice changes within existing resource constraints.

Human Error Analysis and Modeling of Medication-Related Adverse Events in Taiwan Using the Human Factors Analysis and Classification System and Logistic Regression

Medical institutions worldwide strive to avoid adverse medical events, including adverse medication-related events. However, studies on the comprehensive analysis of medication-related adverse events are limited. Therefore, we aimed to identify the error factors contributing to medication-related adverse events using the Human Factors Analysis and Classification System (HFACS) and to develop error models through logistic regression. These models calculate the probability of a medication-related adverse event when a healthcare system defect occurs. Seven experts with at least 12 years of work experience (four nurses and three pharmacists) were recruited to analyze thirty-seven medication-related adverse events. The findings indicate that decision errors, physical/mental limitations, failure to correct problems, and organizational processes were the four factors that most frequently contributed to errors at the four levels of the HFACS. Seven error models of two types (error occurrence and error analysis pathways) were established using logistic regression models, and the relative probabilities of failure factor occurrences were calculated. Based on our results, medical staff can use the error models as a new analytical approach to improve and prevent adverse medication events, thereby improving patient safety.

Rates of perceived medical errors and its correlation with work-related factors and personal distress among emergency physicians in China: a national cross-sectional study

Purpose

Medical errors are a global concern, and specifically, EDs are at considerable risk for medical errors. Few studies focus on the healthcare provider’s self-perceived medical errors in hospitals, let alone the ED. Hence, this study explored perceived medical errors and their correlation with work-related factors and personal distress among physicians in EDs in China.

Methods

From July 2018 to August 2018, a national web-based cross-sectional study was conducted. The link to the web-based questionnaire was posted on the emergency physicians’ working platform, inviting Chinese licensed emergency physicians to participate anonymously in this survey. Our outcome of interest, medical errors, was investigated using self-reporting methods. Occupational stress was assessed using the Chinese version of the Effort-Reward Imbalance scale. The Patient Health Questionnaire, the subscale of the 10-item Positive and Negative Affect Schedule, the subscale of the validated Leiden Quality of Work Questionnaire and the 10-item Generalised Self-efficacy Scale were used to assess personal distress. Logistic regression analysis was used to determine factors significantly associated with perceived medical errors.

Results

A sample of 10 457 emergency physicians completed the survey. Almost half (43.63%) of physicians reported self-perceived medical errors during the previous 3 months. The rate of workplace verbal aggression, effort-reward imbalance and depressive symptoms were 81.81%, 78.39% and 35.71%, respectively. Medical errors were more likely to be reported among chief physicians, and those who reported the department was short-staffed for physicians, and who experienced workplace verbal aggression and intense work stress. Medical errors were significantly associated with negative affect and lower self-efficacy.

Conclusion

Self-perceived medical errors are prevalent among physicians working in EDs and are associated with their workplace environment and personal distress. Targeted interventions are required to reduce physicians’ workload and improve their working environment. Accounting for healthcare providers’ distress is imperative for reducing the incidence of medical errors and improving their health.

An Investigation of Human Errors in Medication Adverse Event Improvement Priority Using a Hybrid Approach

The aim of this study was to analyze and provide an in-depth improvement priority for medication adverse events. Thus, the Human Factor Analysis and Classification System with subfactors was used in this study to analyze the adverse events. Subsequently, the improvement priority for the subfactors was determined using the hybrid approach in terms of the Analytical Hierarchy Process and the fuzzy Technique for Order of Preference by Similarity to Ideal Solution. In Of the 157 medical adverse events selected from the Taiwan Patient-safety Reporting system, 25 cases were identified as medication adverse events. The Human Factor Analysis and Classification System and root cause analysis were used to analyze the error factors and subfactors that existed in the medication adverse events. Following the analysis, the Analytical Hierarchy Process and the fuzzy Technique for Order of Preference by Similarity to Ideal Solution were used to determine the improvement priority for subfactors. The results showed that the decision errors, crew resource management, inadequate supervision, and organizational climate contained more types of subfactors than other error factors in each category. In the current study, 16 improvement priorities were identified. According to the results, the improvement priorities can assist medical staff, researchers, and decisionmakers in improving medication process deficiencies efficiently.

HEART Score in Predicting One-Month Major Adverse Cardiac Events in Patients with Acute Chest Pain; a Diagnostic Accuracy Study

Introduction

Screening of high-risk patients and accelerating their therapeutic procedures can reduce the burden of acute coronary syndrome (ACS). This study aimed to evaluate the accuracy of HEART score in predicting the risk of one-month major adverse cardiac events (MACE) in these patients.

Methods

In this prospective cross-sectional study, the accuracy of HEART score in patients over 18 years old who presented to emergency department following acute chest pain, was evaluated during a 21-month period. Each patient was followed up regarding the incidence of MACE for one month via phone call and the hospital's integrated health information system.

Results

240 cases with the mean age of 60.50 ± 16.07 years were studied (56.3% male). MACE was observed in 77 (32.1%) cases. The most common MACE was percutaneous coronary artery revascularization (PCAR) (12.9%). The mean HEART score of studied cases was 4.74 ± 2.12. The mean score of cases with MACE was significantly higher than others (6.25 ± 1.97 versus 4.03 ± 1.79; p < 0.0001). Based on this score, the risk of MACE was high in 34 (14.2%), moderate in 118 (49.2%), and low in 88 (36.7%) cases. The incidence of one-month MACE was 85.3% in high-risk cases, 35.6% in moderate one, and 6.8% in low-risk cases based on HEART score. The area under the ROC curve of HEART score in predicting the risk of MACE was 0.796 (95% CI: 0.736 - 0.856). The best cut off point of HEART score in this regard was calculated as 4.5. The sensitivity and specificity of this score in 4.5 cut off were 83.11% (95% CI: 72.49 - 90.35) and 66.25% (95% CI: 58.38 - 73.35), respectively.

Conclusion

Based on the findings of the present study the mean HEART score of ACS patients with one-month MACE was significantly higher than others and the incidence of MACE in high-risk patients was significantly higher. But the overall accuracy of score in predicting one-month MACE in ACS patients was in moderate range.

Perceptions of Emergency Department Triage Nurses About Prehospital Emergency Rescuers in Italy: A Latent Threat to Clinical Handover

OBJECTIVES

In Italy, volunteer rescuers respond to most prehospital emergency calls. These rescuers provide the majority of patient information during handover at the emergency department triage. Standardized terminology between rescuers and triage nurses is lacking in Italy, and miscommunication may cause a poor handover. Even though rescuers are professional health providers, their qualification is not legally recognized, and triage nurses have a pervasive sense of inadequacy about the rescuers' competences.This work explored triage nurses' perceptions of rescuers and the causes of these perceptions to verify whether difficult interprofessional relationships negatively influence the clinical handover process.

METHODS

We performed a survey among 402 triage nurses for 3 main areas of rescuers' competency: communication, knowledge, and decision making. For each area, we identified communications, decision making, and knowledge indicators. A scale score of 6 or higher was considered not sufficient.

RESULTS

We found that 75.5% (n = 302/400) of triage nurses regard rescuers' ability to recognize life-threatening situations as not sufficient (communication ability indicator). Approximately 66% (n = 264/401) of triage nurses regard rescuers' ability to administer oxygen as not sufficient (decision-making indicator), and approximately 58% (n = 232/402) of nurses regard rescuers' ability to report the reason for the emergency call as not sufficient (knowledge indicator).

CONCLUSIONS

The results of this survey show that the overall perception of triage nurses about prehospital rescuers is slightly below sufficiency. This perception could cause errors during the prehospital or hospital handover at the triage and could lead to delayed decisions and incorrect treatment.

The Association of Nurse Practitioner Scope-of-Practice Laws With Emergency Department Use: Evidence From Medicaid Expansion

BACKGROUND

Overuse and inappropriate use of emergency departments (EDs) remains an important issue in health policy. After implementation of Medicaid expansion, many states experienced an increase in ED use, but the magnitude varied. Differential access to primary care might explain such variation.

OBJECTIVE

To determine whether the increase in ED use among Medicaid enrollees following Medicaid expansion was smaller in states that allowed greater access to primary care providers by permitting nurse practitioners (NPs) to practice without physician oversight.

RESEARCH DESIGN

Examining data on ED use by Medicaid beneficiaries, we estimated random effects models to examine changes in ED visits. Models for 8 different clinical conditions were estimated, with each model including a linear time trend, indicators for Medicaid expansion and for the absence of physician oversight requirements, and an interaction between these 2 indicators.

RESULTS

States requiring physician oversight of NPs had a 28% increase in ED visits relative to the preexpansion period, while states allowing NP practice without physician oversight had only a 7% increase. The increase in the share of visits covered by Medicaid in no-oversight states was 40% of the size of the increase in oversight states.

CONCLUSIONS

Allowing NPs to practice without physician oversight was associated with a reduction in the magnitude of increase in ED use following Medicaid expansion. States that restrict NP practice should weigh the costs of maintaining these restrictions against the potential benefits of lower ED use. States considering Medicaid expansion should also consider relaxing NP scope-of-practice laws.

Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors

Lack of verification is often cited as a root cause of medication errors; however, medication errors occur in spite of conventional verification practices and it appears that human factors engineering (HFE) can inform the design of a more effective method. To this end, an HFE-driven process was designed and implemented in an urban, Midwestern emergency medical service agency. Medication error data were collected over a 54-month period, 27 months before and after implementation. A decrease in the average monthly error rate was realized for all medications administered (49.0%) during the post-intervention time period. The average monthly error rate for fentanyl, a commonly administered analgesic, demonstrated a 71.1% error rate decrease. This study is the first to evaluate the effectiveness of a team-based cross-check process for medication verification to prevent errors in the prehospital setting.

Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department: The CHARMED Cluster Randomized Trial

IMPORTANCE

Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved.

OBJECTIVE

To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized crossover trial includes a random sample of 14 adult patients (age ≥18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France.

INTERVENTIONS

Systematic cross-checking between emergency physicians, 3 times a day, which included a brief presentation of one physician's case to another, followed by the second physician's feedback to the first.

MAIN OUTCOMES AND MEASURES

Medical error in the ED, defined as an adverse event (either a near miss or a serious adverse event). The primary end point was identified using a 2-level error detection surveillance system, blinded to the strategy allocation.

RESULTS

Among the 1680 included patients (mean [SD] age, 57.5 [21.7] years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) in the cross-check group compared with 90 adverse events among 840 patients (10.7%) in the standard care group (relative risk reduction [RRR], 40% [95% CI, 12% to 59%]; absolute risk reduction [ARR], 4.3%; number needed to treat [NNT], 24). There was also a significant reduction rate of near misses (RRR, 47% [95% CI, 15% to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of preventable serious adverse events (RRR, 29% [95% CI, -18% to 57%]; ARR, 1.2%; NNT, 83).

CONCLUSIONS AND RELEVANCE

The implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02356926.

The ability of triggers to retrospectively predict potentially preventable adverse events in a sample of deceased patients

Several trigger systems have been developed to screen medical records of hospitalized patients for adverse events (AEs). Because it's too labor-intensive to screen the records of all patients, usually a sample is screened. Our sample consists of patients who died during their stay because chances of finding preventable AEs in this subset are highest. Records were reviewed for fifteen triggers (n = 2182). When a trigger was present, the records were scrutinized by specialized medical doctors who searched for AEs. The positive predictive value (PPV) of the total trigger system and of the individual triggers was calculated. Additional analyses were performed to identify a possible optimization of the trigger system. In our sample, the trigger system had an overall PPV for AEs of 47%, 17% for potentially preventable AEs. More triggers present in a record increased the probability of detecting an AE. Adjustments to the trigger system slightly increased the positive predictive value but missed about 10% of the AEs detected with the original system. In our sample of deceased patients the trigger system has a PPV comparable to other samples. However still, an enormous amount of time and resources are spent on cases without AEs or with non-preventable AEs. Possibly, the performance could be further improved by combining triggers with clinical scores and laboratory results. This could be promising in reducing the costly and labor-intensive work of screening medical records.

Review article: A systematic review of emergency department incident classification frameworks

As in any part of the hospital system, safety incidents can occur in the ED. These incidents arguably have a distinct character, as the ED involves unscheduled flows of urgent patients who require disparate services. To aid understanding of safety issues and support risk management of the ED, a comparison of published ED specific incident classification frameworks was performed. A review of emergency medicine, health management and general medical publications, using Ovid SP to interrogate Medline (1976-2016) was undertaken to identify any type of taxonomy or classification-like framework for ED related incidents. These frameworks were then analysed and compared. The review identified 17 publications containing an incident classification framework. Comparison of factors and themes making up the classification constituent elements revealed some commonality, but no overall consistency, nor evolution towards an ideal framework. Inconsistency arises from differences in the evidential basis and design methodology of classifications, with design itself being an inherently subjective process. It was not possible to identify an 'ideal' incident classification framework for ED risk management, and there is significant variation in the selection of categories used by frameworks. The variation in classification could risk an unbalanced emphasis in findings through application of a particular framework. Design of an ED specific, ideal incident classification framework should be informed by a much wider range of theories of how organisations and systems work, in addition to clinical and human factors.

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

OBJECTIVES

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors.

METHODS

Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors.

RESULTS

Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents.

CONCLUSIONS

Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED.

Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study

BACKGROUND

Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10% of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED.

DESIGN

The CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6% - 1584 patients will be included, 140 for each period in each center.

DISCUSSION

The CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors.

TRIAL REGISTRATION

Clinical Trials, NCT02356926.

Unexpected death within 72 hours of emergency department visit: were those deaths preventable?

Introduction

We aimed to determine the rate of preventable death in patients who died early and unexpectedly following hospital admission from the emergency department (ED).

Methods

We conducted a retrospective multicenter study in four centers from the Paris metropolitan area. Inclusion criteria were medical patients who died in hospital within 72 hours of ED attendance and were not admitted to the intensive care unit (unexpected death). Exclusion criteria were limitations of care determined by treating physicians. The existence of a limitation of care decision was adjudicated by two independent chart abstractors. Preventable death was defined as death occurring as a result of medical error. For each selected patient with unexpected death, charts were examined for medical errors and rated on a 1 to 5 preventability scale (from very unlikely to very likely) for the preventability of the death. The primary endpoint was the likely preventable death, rated as 4 or 5 on the preventability scale.

Results

We retrieved 555 charts; 47 unexpected deaths were analysed; 24 (51%) were considered as preventable. There was a median number of medical errors of two. The most common process breakdowns were incorrect choice of treatment (47% of patients) and failure to order appropriate diagnostic tests (38% of patients). The most common medical error was a severe delay or absence of recommended treatment for severe sepsis, which occurred in 10 (42%) patients.

Conclusions

In our sample, more than half of unexpected deaths are related to a medical error, and could have been prevented.