Case-control study to investigate variables associated with incidents and adverse events in the emergency department

Diagnostic Errors in Japanese Community Hospitals and Related Factors: A Retrospective Cohort Study

Diagnostic error has recently become a crucial clinical problem and an area of intense research. However, the reality of diagnostic errors in regional hospitals remains unknown. This study aimed to clarify the reality of diagnostic errors in regional hospitals in Japan. A 10-month retrospective cohort study was conducted from January to October 2021 at the emergency room of Oda Municipal Hospital in central Shimane Prefecture, Japan. Participants were divided into groups with or without diagnostic errors, and independent variables of patient, physician, and environmental factors were analyzed using Fisher's exact test, univariate (Student's t-test and Welch's t-test), and logistic regression analyses. Diagnostic errors accounted for 13.1% of all eligible cases. Remarkably, the proportion of patients treated without oxygen support and the proportion of male patients were significantly higher in the group with diagnostic errors. Sex bias was present. Additionally, cognitive bias, a major factor in diagnostic errors, may have occurred in patients who did not require oxygen support. Numerous factors contribute to diagnostic errors; however, it is important to understand the trends in the setting of each healthcare facility and plan and implement individualized countermeasures.

Feasibility of a rapid diagnosis discussion tool for reducing misdiagnosis of patients presenting to emergency departments with abdominal pain

OBJECTIVES

Providing accurate and timely diagnoses is challenging in ED settings. We evaluated the feasibility and effectiveness of a short, structured rapid diagnosis discussion (RaDD) between a patient's initial doctor and a second doctor for patients presenting to ED with abdominal pain.

METHODS

Controlled pre-post, mixed-methods pilot study in a metropolitan hospital network in Melbourne, Australia. Comparisons were made between an ED using RaDD for a 1-month period (n = 155) and two control EDs within the same hospital network (n = 2227) using standard practices. A short survey of 27 clinicians was also undertaken.

RESULTS

Provisional diagnoses changed in 24.7% (95% confidence interval 19.0, 30.4) of all cases for which a RaDD case report sheet was completed, and clinicians' confidence in their decision-making was significantly higher when using RaDD (r = 0.27). RaDD significantly increased the likelihood that patients would be sent to the short stay unit and have a blood test ordered, and significantly reduced the likelihood that patients would be discharged home from the ED or leave at their own risk. Usage of the RaDD tool was low (25.2% of eligible cases), and qualitative feedback indicated that time limitations inhibited uptake.

CONCLUSIONS

RaDD encouraged clinicians to take a more cautious, risk-averse approach to care and improved confidence in their diagnostic decisions. However, cost effectiveness of these outcomes and possible implementation barriers need to be further considered in subsequent studies.

Analysis of Risk Factors for Patient Safety Events Occurring in the Emergency Department

OBJECTIVE

The aim of the study was to describe and analyze the risk factors associated with patient safety events (PSEs), defined as adverse events (AEs), preventable AEs (PAEs), and near-miss events (NMEs), in the emergency department (ED).

METHODS

It was a retrospective cohort study using ED patients' data retrieved from January 2010 to December 2016. Quality assurance issues (QAIs) used as triggers included the following: issues during procedural sedation, death within 24 hours of admission, patients' and physicians' complaints, returns to the ED within 72 hours, and transfers to an intensive care unit within 24 hours.

RESULTS

Of 383,586 ED visits, 6519 (1.7%) QAIs were reported with a PSEs incidence of 6.1%. Among the 397 PSEs, 258 were AEs including 82 PAEs, and 139 NMEs. During the 7-year period, we observed a fourfold increase in NMEs, and despite a decrease in the rate of AEs with the highest (3.1%) and lowest (0.8%) incidence in 2011 and 2016, respectively, the incidence of PAEs events remained relatively constant. Unadjusted analysis showed that ED waiting time, boarding time, ED length of stay (LOS), ED disposition, as well as diagnostic and QAIs were significantly related to PSEs (P < 0.05). Multivariable analysis showed that the type of QAIs and diagnostic were associated with PSEs (P < 0.001). Type of QAIs was a risk factor for AEs and PAEs occurrence and factors involved in NMEs were type of QAIs (P = 0.02) and ED LOS (P < 0.001). "The odds of a PSE occurring increased by 0.2% for each additional minute increase in the ED waiting time, by 5.2% for each additional boarding hour, and by 4.5% for each ED LOS hour."

CONCLUSIONS

This study showed several potential risk factors for PSEs, especially ED LOS, type of QAIs, and diagnostic. Systematic interventions might have more impact on risk of PSE.

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

OBJECTIVE

To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

REVIEW METHODS

Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

RESULTS

Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).

CONCLUSIONS

Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.