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Chen TY, Huang TY, Chang YC. Using a clinical narrative-aware pre-trained language model for predicting emergency department patient disposition and unscheduled return visits. J Biomed Inform 2024; 155:104657. [PMID: 38772443 DOI: 10.1016/j.jbi.2024.104657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/07/2024] [Accepted: 05/18/2024] [Indexed: 05/23/2024]
Abstract
The increasing prevalence of overcrowding in Emergency Departments (EDs) threatens the effective delivery of urgent healthcare. Mitigation strategies include the deployment of monitoring systems capable of tracking and managing patient disposition to facilitate appropriate and timely care, which subsequently reduces patient revisits, optimizes resource allocation, and enhances patient outcomes. This study used ∼ 250,000 emergency department visit records from Taipei Medical University-Shuang Ho Hospital to develop a natural language processing model using BlueBERT, a biomedical domain-specific pre-trained language model, to predict patient disposition status and unplanned readmissions. Data preprocessing and the integration of both structured and unstructured data were central to our approach. Compared to other models, BlueBERT outperformed due to its pre-training on a diverse range of medical literature, enabling it to better comprehend the specialized terminology, relationships, and context present in ED data. We found that translating Chinese-English clinical narratives into English and textualizing numerical data into categorical representations significantly improved the prediction of patient disposition (AUROC = 0.9014) and 72-hour unscheduled return visits (AUROC = 0.6475). The study concludes that the BlueBERT-based model demonstrated superior prediction capabilities, surpassing the performance of prior patient disposition predictive models, thus offering promising applications in the realm of ED clinical practice.
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Affiliation(s)
- Tzu-Ying Chen
- Graduate Institute of Data Science, Taipei Medical University, Taipei City, Taiwan
| | - Ting-Yun Huang
- Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yung-Chun Chang
- Graduate Institute of Data Science, Taipei Medical University, Taipei City, Taiwan; Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei City, Taiwan.
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Mangus CW, James TG, Parker SJ, Duffy E, Chandanabhumma PP, Cassady CM, Bellolio F, Pasupathy KS, Manojlovich M, Singh H, Mahajan P. Frontline Providers' and Patients' Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study. Jt Comm J Qual Patient Saf 2024; 50:480-491. [PMID: 38643047 DOI: 10.1016/j.jcjq.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety. METHODS Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED-Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews. RESULTS The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED-Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused. CONCLUSION Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.
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Hsu CC, Chu CCJ, Ng CJ, Lin CH, Lo HY, Chen SY. Machine learning models for predicting unscheduled return visits of patients with abdominal pain at emergency department and validation during COVID-19 pandemic: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e37220. [PMID: 38394532 DOI: 10.1097/md.0000000000037220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
Machine learning (ML) models for predicting 72-hour unscheduled return visits (URVs) for patients with abdominal pain in the emergency department (ED) were developed in a previous study. This study refined the data to adjust previous prediction models and evaluated the model performance in future data validation during the COVID-19 era. We aimed to evaluate the practicality of the ML models and compare the URVs before and during the COVID-19 pandemic. We used electronic health records from Chang Gung Memorial Hospital from 2018 to 2019 as a training dataset, and various machine learning models, including logistic regression (LR), random forest (RF), extreme gradient boosting (XGB), and voting classifier (VC) were developed and subsequently used to validate against the 2020 to 2021 data. The models highlighted several determinants for 72-hour URVs, including patient age, prior ER visits, specific vital signs, and medical interventions. The LR, XGB, and VC models exhibited the same AUC of 0.71 in the testing set, whereas the VC model displayed a higher F1 score (0.21). The XGB model demonstrated the highest specificity (0.99) and precision (0.64) but the lowest sensitivity (0.01). Among these models, the VC model showed the most favorable, balanced, and comprehensive performance. Despite the promising results, the study illuminated challenges in predictive modeling, such as the unforeseen influences of global events, such as the COVID-19 pandemic. These findings not only highlight the significant potential of machine learning in augmenting emergency care but also underline the importance of iterative refinement in response to changing real-world conditions.
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Affiliation(s)
- Chun-Chuan Hsu
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taoyuan City 333, Taiwan
| | - Cheng-C J Chu
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taoyuan City 333, Taiwan
| | - Ching-Heng Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- Bachelor Program in Artificial Intelligence, Chang Gung University, Taoyuan City 333, Taiwan
| | - Hsiang-Yun Lo
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taoyuan City 333, Taiwan
| | - Shou-Yen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taoyuan City 333, Taiwan
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Lee YC, Ng CJ, Hsu CC, Cheng CW, Chen SY. Machine learning models for predicting unscheduled return visits to an emergency department: a scoping review. BMC Emerg Med 2024; 24:20. [PMID: 38287243 PMCID: PMC10826225 DOI: 10.1186/s12873-024-00939-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 01/22/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Unscheduled return visits (URVs) to emergency departments (EDs) are used to assess the quality of care in EDs. Machine learning (ML) models can incorporate a wide range of complex predictors to identify high-risk patients and reduce errors to save time and cost. However, the accuracy and practicality of such models are questionable. This review compares the predictive power of multiple ML models and examines the effects of multiple research factors on these models' performance in predicting URVs to EDs. METHODS We conducted the present scoping review by searching eight databases for data from 2010 to 2023. The criteria focused on eligible articles that used ML to predict ED return visits. The primary outcome was the predictive performances of the ML models, and results were analyzed on the basis of intervals of return visits, patient population, and research scale. RESULTS A total of 582 articles were identified through the database search, with 14 articles selected for detailed analysis. Logistic regression was the most widely used method; however, eXtreme Gradient Boosting generally exhibited superior performance. Variations in visit interval, target group, and research scale did not significantly affect the predictive power of the models. CONCLUSION This is the first study to summarize the use of ML for predicting URVs in ED patients. The development of practical ML prediction models for ED URVs is feasible, but improving the accuracy of predicting ED URVs to beyond 0.75 remains a challenge. Including multiple data sources and dimensions is key for enabling ML models to achieve high accuracy; however, such inclusion could be challenging within a limited timeframe. The application of ML models for predicting ED URVs may improve patient safety and reduce medical costs by decreasing the frequency of URVs. Further research is necessary to explore the real-world efficacy of ML models.
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Affiliation(s)
- Yi-Chih Lee
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan City, 333, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan City, 333, Taiwan
| | - Chun-Chuan Hsu
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan City, 333, Taiwan
| | - Chien-Wei Cheng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, No. 5 Fushing St., Gueishan Shiang, Taoyuan City, 333, Taiwan
| | - Shou-Yen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taoyuan City, 333, Taiwan.
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, No. 5 Fushing St., Gueishan Shiang, Taoyuan City, 333, Taiwan.
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Aengst J, Walker-Stevenson G, Harrod T, Ivankovic J, Neilson J, Guise JM. Uncomfortable yet necessary: The impact of PPE on communication in emergency medicine. Int J Qual Health Care 2022; 34:6854825. [PMID: 36448555 PMCID: PMC9782918 DOI: 10.1093/intqhc/mzac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/09/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The efficacy of pre-hospital emergency services is heavily dependent on the effective communication of care providers. This effective communication occurs between providers as part of a team and also among providers interacting with family members and patients. The COVID-19 pandemic introduced a number of communication challenges to emergency care, which are primarily linked to the increased use of personal protective equipment (PPE). OBJECTIVE We sought to analyze the impacts of the COVID-19 pandemic on emergency medical service (EMS) workers and pre-hospital care delivery. METHODS We conducted focus groups and one-on-one interviews with fire-based EMS first responders between September 2021 and 2022. Interviews included questions about job-related stress, EMS skills, work experiences and changes during COVID-19. Interviews were recorded, independently dual coded and analyzed for themes. RESULTS Two hundred twenty-three first responders participated in 40 focus groups and 40 lead paramedics participated in individual interviews. We found that additional use of PPE was reported to have significantly impaired efficiency and perceptions of quality of care-among EMS team members and also between EMS workers and patients. EMS personnels also experienced on-scene hostility on arrival (from both families and other agencies). Extensive use of PPE muffles voices, obscures facial expressions and can cause team members to have difficulty recognizing and communicating with one another and can be a barrier to showing empathy and connecting with patients. Creative solutions such as putting a hand on someone's shoulder, wearing name tags on suits and explaining rationale for perceived delays were mentioned as methods to transcend these barriers. The appearance of providers in heavy PPE can be unsettling and create barriers to human connection, particularly for pediatric patients. CONCLUSION Human connection is an important element of health-care delivery and healing. These findings shed light on new skills that are needed to initiate and maintain human connection in these times of PPE use, especially full-body PPE. Awareness of the communication and empathy barriers posed by PPE is the first step to improving provider-patient interactions in pre-hospital EMS. Additionally, 'communication-friendly' adaptations of PPE equipment may be an important area for future research and development in manufacturing and the health-care industry.
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Affiliation(s)
- Jennifer Aengst
- Department of Anthropology, Portland State University, P.O. Box 751, Portland, OR 97207, USA
| | - Grace Walker-Stevenson
- Address reprint requests to: Grace Walker-Stevenson, Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA. Tel: +503-494-3666; Fax: +503-494-2391; E-mail:
| | - Tabria Harrod
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jonathan Ivankovic
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jacob Neilson
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jeanne-Marie Guise
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
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Intravenous antibiotics at the index emergency department visit as an independent risk factor for hospital admission at the return visit within 72 hours. PLoS One 2022; 17:e0264946. [PMID: 35303001 PMCID: PMC8932564 DOI: 10.1371/journal.pone.0264946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases. Material and methods This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits. Results Patients receiving intravenous antibiotics at index visits had significantly higher risk—approximately two times—for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34–4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels. Conclusions Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics.
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A Machine Learning Model for Predicting Unscheduled 72 h Return Visits to the Emergency Department by Patients with Abdominal Pain. Diagnostics (Basel) 2021; 12:diagnostics12010082. [PMID: 35054249 PMCID: PMC8775134 DOI: 10.3390/diagnostics12010082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
Seventy-two-hour unscheduled return visits (URVs) by emergency department patients are a key clinical index for evaluating the quality of care in emergency departments (EDs). This study aimed to develop a machine learning model to predict 72 h URVs for ED patients with abdominal pain. Electronic health records data were collected from the Chang Gung Research Database (CGRD) for 25,151 ED visits by patients with abdominal pain and a total of 617 features were used for analysis. We used supervised machine learning models, namely logistic regression (LR), support vector machine (SVM), random forest (RF), extreme gradient boosting (XGB), and voting classifier (VC), to predict URVs. The VC model achieved more favorable overall performance than other models (AUROC: 0.74; 95% confidence interval (CI), 0.69–0.76; sensitivity, 0.39; specificity, 0.89; F1 score, 0.25). The reduced VC model achieved comparable performance (AUROC: 0.72; 95% CI, 0.69–0.74) to the full models using all clinical features. The VC model exhibited the most favorable performance in predicting 72 h URVs for patients with abdominal pain, both for all-features and reduced-features models. Application of the VC model in the clinical setting after validation may help physicians to make accurate decisions and decrease URVs.
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Liu WC, Lin CS, Tsai CS, Tsao TP, Cheng CC, Liou JT, Lin WS, Cheng SM, Lou YS, Lee CC, Lin C. A deep learning algorithm for detecting acute myocardial infarction. EUROINTERVENTION 2021; 17:765-773. [PMID: 33840640 PMCID: PMC9724911 DOI: 10.4244/eij-d-20-01155] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Delayed diagnosis or misdiagnosis of acute myocardial infarction (AMI) is not unusual in daily practice. Since a 12-lead electrocardiogram (ECG) is crucial for the detection of AMI, a systematic algorithm to strengthen ECG interpretation may have important implications for improving diagnosis. AIMS We aimed to develop a deep learning model (DLM) as a diagnostic support tool based on a 12-lead electrocardiogram. METHODS This retrospective cohort study included 1,051/697 ECGs from 737/287 coronary angiogram (CAG)-validated STEMI/NSTEMI patients and 140,336 ECGs from 76,775 non-AMI patients at the emergency department. The DLM was trained and validated in 80% and 20% of these ECGs. A human-machine competition was conducted. The area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to evaluate the performance of the DLM. RESULTS The AUC of the DLM for STEMI detection was 0.976 in the human-machine competition, which was significantly better than that of the best physicians. Furthermore, the DLM independently demonstrated sufficient diagnostic capacity for STEMI detection (AUC=0.997; sensitivity, 98.4%; specificity, 96.9%). Regarding NSTEMI detection, the AUC of the combined DLM and conventional cardiac troponin I (cTnI) increased to 0.978, which was better than that of either the DLM (0.877) or cTnI (0.950). CONCLUSIONS The DLM may serve as a timely, objective and precise diagnostic decision support tool to assist emergency medical system-based networks and frontline physicians in detecting AMI and subsequently initiating reperfusion therapy.
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Affiliation(s)
- Wen-Cheng Liu
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Tien-Ping Tsao
- Division of Cardiology, Heart Centre, Cheng Hsin Hospital, Taipei, Taiwan, R.O.C
| | - Cheng-Chung Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Jun-Ting Liou
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Yu-Sheng Lou
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Chia-Cheng Lee
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C,Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Chin Lin
- No.161 Min-Chun E. Rd, Sec. 6, Neihu, Taipei 114, Taiwan, R.O.C
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Kandasamy S, Vanstone M, Colvin E, Chan T, Sherbino J, Monteiro S. "I made a mistake!": A narrative analysis of experienced physicians' stories of preventable error. J Eval Clin Pract 2021; 27:236-245. [PMID: 33399266 DOI: 10.1111/jep.13531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 01/01/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how generalist physicians make meaning of and grow from their medical errors. METHODS This study used a narrative inquiry approach to conduct and analyse in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analysed them for key components, and rewrote a "meta-story" in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice. RESULTS Through analysis we interpreted the story of a physician who is required to make numerous decisions in a short period of time in different clinical environments among the patient's family and whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the clinical supervisor can help optimize the physician's emotional growth and professional development. Similarly, through sharing and learning from stories, colleagues and trainees can also contribute to the growth of the protagonist's character and the development of clinic, hospital, and healthcare system. CONCLUSION We draw parallels between the clinical setting and a generalist physician's experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.
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Affiliation(s)
- Sujane Kandasamy
- Department of Health Research Methods, Evidence & Impact, Health Research Methodology PhD Program, McMaster University, Hamilton, Ontario, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.,McMaster Education Research, Innovation & Theory (MERIT) Program, McMaster University, Hamilton, Ontario, Canada
| | - Eamon Colvin
- School of Psychology, Clinical Psychology PhD Program, University of Ottawa, Ottawa, Ontario, Canada
| | - Teresa Chan
- McMaster Education Research, Innovation & Theory (MERIT) Program, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.,Program for Faculty Development, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- McMaster Education Research, Innovation & Theory (MERIT) Program, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence & Impact, Health Research Methodology PhD Program, McMaster University, Hamilton, Ontario, Canada.,McMaster Education Research, Innovation & Theory (MERIT) Program, McMaster University, Hamilton, Ontario, Canada
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Sagoo SN, Grytnes R. Involvement un-enabled? An ethnographic study of the challenges and potentials of involving relatives in the acute ambulatory clinical pathway. BMC Health Serv Res 2020; 20:1086. [PMID: 33243218 PMCID: PMC7690026 DOI: 10.1186/s12913-020-05923-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/15/2020] [Indexed: 03/28/2023] Open
Abstract
Background Involving a patient’s relatives is a complex endeavour, especially in emergency departments (EDs). Generally, relatives are recognized as vital partners in health care, but in-depth knowledge on how these family involvement processes take place in the everyday practices of EDs is sparse. The aim of this study is to explore the practice of involving relatives in the acute ambulatory clinical pathway in the ED, as seen from the perspectives of patients and relatives. Methods The study was conducted as ethnographic fieldwork in an ED at a Danish Regional Hospital. Two months of participant-observation were carried out focusing on 43 patients. Of these, 18 patients and/or relatives were selected for telephone interviews after 1 week, and of these 11 were selected for in-depth interviews 3 weeks later. Results Unpredictability is a basic condition of any ED. For the patients and relatives, who are unfamiliar with the routines in the ED, unpredictability translates to a sense of temporal and existential unpredictability, reinforced by a sense of not knowing when the examinations will be completed or if/when they will be sent home. Relatives’ involvement in the ED is affected by this sense of unpredictability and by the existing relations between patients and their relatives prior to entering the ED. The stay in the ED is only one ‘stop’ in the complete acute ambulatory clinical pathway but relatives’ involvement also concerns the time before and after the stay in the ED. Practices of involving relatives leave (some) relatives invisible in the clinical pathway. As a consequence, they are often not addressed, which un-enables their involvement. Conclusion Involvement of relatives presupposes recognizing the relatives as participants if they are to be involved in the patient’s clinical pathway in the ED. As a start, it is advisable that the medical staff ask the patients on arrival who has accompanied them in the ED, and if and in what way they want their companions involved in the ED. There is a need for a more integrated and contextualized understanding of relatives’ involvement, as it takes place along an extended acute ambulatory clinical pathway. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05923-x.
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Affiliation(s)
- Susanne Nissen Sagoo
- Department. of Occupational Medicine, University Research Clinic, Regional Hospital West Jutland, Gl. Landevej 61, Herning, Denmark.
| | - Regine Grytnes
- Department. of Occupational Medicine, University Research Clinic, Regional Hospital West Jutland, Gl. Landevej 61, Herning, Denmark
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Abstract
BACKGROUND Incident reporting is a recognized tool for healthcare quality improvement. These systems, which aim to capture near-misses and harm events, enable organizations to gather critical information about failure modes and design mitigation strategies. Although many hospitals have employed these systems, little is known about safety themes in emergency medicine incident reporting. Our objective was to systematically analyze and thematically code 1 year of incident reports. METHODS A mixed-methods analysis was performed on 1 year of safety reporting data from a large, urban tertiary-care emergency department using a modified grounded theory approach. RESULTS Between January 1 and December 31, 2015, there were 108,436 emergency department visits. During this time, 750 incident reports were filed. Twenty-nine themes were used to code the reports, with 744 codes applied. The most common themes were related to delays (138/750, 18.4%), medication safety (136/750, 18.1%), and failures in communication (110/750, 14.7%). A total of 48.8% (366/750) of reports were submitted by nurses. CONCLUSIONS The most prominent themes during 1 year of incident reports were related to medication safety, delays, and communication. Relative to hospital-wide reporting patterns, a higher proportion of reports were submitted by physicians. Despite this, overall incident reporting remains low, and more is needed to engage physicians in reporting.
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Lin CS, Lin C, Fang WH, Hsu CJ, Chen SJ, Huang KH, Lin WS, Tsai CS, Kuo CC, Chau T, Yang SJ, Lin SH. A Deep-Learning Algorithm (ECG12Net) for Detecting Hypokalemia and Hyperkalemia by Electrocardiography: Algorithm Development. JMIR Med Inform 2020; 8:e15931. [PMID: 32134388 PMCID: PMC7082733 DOI: 10.2196/15931] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/28/2019] [Accepted: 12/15/2019] [Indexed: 01/17/2023] Open
Abstract
Background The detection of dyskalemias—hypokalemia and hyperkalemia—currently depends on laboratory tests. Since cardiac tissue is very sensitive to dyskalemia, electrocardiography (ECG) may be able to uncover clinically important dyskalemias before laboratory results. Objective Our study aimed to develop a deep-learning model, ECG12Net, to detect dyskalemias based on ECG presentations and to evaluate the logic and performance of this model. Methods Spanning from May 2011 to December 2016, 66,321 ECG records with corresponding serum potassium (K+) concentrations were obtained from 40,180 patients admitted to the emergency department. ECG12Net is an 82-layer convolutional neural network that estimates serum K+ concentration. Six clinicians—three emergency physicians and three cardiologists—participated in human-machine competition. Sensitivity, specificity, and balance accuracy were used to evaluate the performance of ECG12Net with that of these physicians. Results In a human-machine competition including 300 ECGs of different serum K+ concentrations, the area under the curve for detecting hypokalemia and hyperkalemia with ECG12Net was 0.926 and 0.958, respectively, which was significantly better than that of our best clinicians. Moreover, in detecting hypokalemia and hyperkalemia, the sensitivities were 96.7% and 83.3%, respectively, and the specificities were 93.3% and 97.8%, respectively. In a test set including 13,222 ECGs, ECG12Net had a similar performance in terms of sensitivity for severe hypokalemia (95.6%) and severe hyperkalemia (84.5%), with a mean absolute error of 0.531. The specificities for detecting hypokalemia and hyperkalemia were 81.6% and 96.0%, respectively. Conclusions A deep-learning model based on a 12-lead ECG may help physicians promptly recognize severe dyskalemias and thereby potentially reduce cardiac events.
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Affiliation(s)
- Chin-Sheng Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Research and Development, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Hui Fang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Jung Hsu
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Sy-Jou Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Hua Huang
- Planning and Management Office, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chun Kuo
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Tom Chau
- Department of Medicine, Providence St Vincent Medical Center, Portland, OR, United States
| | - Stephen Jh Yang
- Department of Computer Science and Information Engineering, National Central University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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13
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Guo DY, Chen KH, Chen IC, Lu KY, Lin YC, Hsiao KY. The Association Between Emergency Department Revisit and Elderly Patients. J Acute Med 2020; 10:20-26. [PMID: 32995151 PMCID: PMC7517912 DOI: 10.6705/j.jacme.202003_10(1).0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emergency department (ED) revisits may be associated with a higher percentage of adverse events and increased costs. Our hospital is a university affiliation hospital accepted regional referral patients, and located in the region in Taiwan with the highest percentage of elderly people. In this study, we attempted to identify whether old age was a risk factor of ED revisit. METHODS Patients who visited the ED from July 2011 to June 2016 were included. Factors associated with revisit were collected from medical information database. A total of 239,405 patients were included in our study, with 13,272 having ED revisits within 72 hours. Chi square and independent t test were applied for univariable factors, and a logistic regression model was used for multivariable analysis. RESULTS Old age (age ≥ 65 years) was found to be a risk factor for ED revisit (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.09-1.19). Diagnosis, pulse rate, diastolic blood pressure, fever, pain management, paracentesis, triage level, registration category, male gender, discharge status, and major illness may have some effect on ED revisit. CONCLUSIONS In our patients, old age is a risk factor for ED revisit; however, only a weak association was found.
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Affiliation(s)
- Di-You Guo
- Chang Gung Memorial Hospital, Chiayi Department of Emergency Medicine Chiayi Taiwan
| | - Kai-Hua Chen
- Chang Gung Memorial Hospital Department of Physical Medicine and Rehabilitation Chiayi Taiwan
| | - I-Chuan Chen
- Chang Gung Memorial Hospital, Chiayi Department of Emergency Medicine Chiayi Taiwan
- Chang Gung University of Science and Technology Department of Nursing Chiayi Taiwan
| | - Kuan-Yu Lu
- Chang Gung Memorial Hospital Department of Physical Medicine and Rehabilitation Chiayi Taiwan
| | - Yu-Ching Lin
- Chang Gung University of Science and Technology Department of Respiratory Care Chiayi Taiwan
- Chang Gung Memorial Hospital Division of Pulmonary and Critical Care Medicine Chiayi Taiwan
- Chang Gung University School of Medicine Taoyuan Taiwan
| | - Kuang-Yu Hsiao
- Chang Gung Memorial Hospital, Chiayi Department of Emergency Medicine Chiayi Taiwan
- Shu-Zen Junior College of Medicine and Management Department of Optometry Taiwan
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14
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Mangus CW, Mahajan P. Common Medical Errors in Pediatric Emergency Medicine. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.100714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Abstract
Emergency medicine requires diagnosing unfamiliar patients with undifferentiated acute presentations. This requires hypothesis generation and questioning, examination, and testing. Balancing patient load, care across the severity spectrum, and frequent interruptions create time pressures that predispose humans to fast thinking or cognitive shortcuts, including cognitive biases. Diagnostic error is the failure to establish an accurate and timely explanation of the problem or communicate that to the patient, often contributing to physical, emotional, or financial harm. Methods for monitoring diagnostic error in the emergency department are needed to establish frequency and serve as a foundation for future interventions.
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Affiliation(s)
- Laura N Medford-Davis
- Department of Emergency Medicine, Ben Taub General Hospital, 1504 Taub Loop, Houston, TX 77030, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX 77030, USA
| | - Prashant Mahajan
- Department of Emergency Medicine, CS Mott Children's Hospital of Michigan, 1540 East Hospital Drive, Room 2-737, SPC 4260, Ann Arbor, MI 48109-4260, USA
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16
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Aaronson EL, White BA, Black L, Brown DF, Benzer T, Castagna A, Raja AS, Sonis J, Mort E. Training to Improve Communication Quality: An Efficient Interdisciplinary Experience for Emergency Department Clinicians. Am J Med Qual 2018; 34:260-265. [PMID: 30235933 DOI: 10.1177/1062860618799936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-provider communication has been recognized as a critical area of focus for improved health care quality, with a mounting body of evidence tying patient satisfaction and provider communication to important health care outcomes. Despite this, few programs have been studied in the emergency department (ED) setting. The authors designed a communication curriculum and conducted trainings for all ED clinical staff. Although only 72% of clinicians believed the course would be a valuable use of their time before taking it, 97% reported that it was a valuable use of their time after ( P < .001). Pre-course self-evaluation of knowledge, skill, and ability were high. Despite this, post-course self-efficacy improved statistically significantly. This study suggests that it is possible, in a brief training session, to deliver communication content that participants felt was relevant to their practice, improved their skills and knowledge, changed their attitude, and was perceived to be a valuable use of their time.
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Affiliation(s)
- Emily L Aaronson
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA.,2 Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA
| | - Benjamin A White
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lauren Black
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David F Brown
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore Benzer
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Allison Castagna
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ali S Raja
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jonathan Sonis
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Elizabeth Mort
- 1 Massachusetts General Hospital, Harvard Medical School, Boston, MA.,2 Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA
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17
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Loi SL, Hj Fauzi MH, Md Noh AY. Unscheduled early revisit to emergency department. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918767012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Unscheduled revisits to the emergency department may present a considerable additional workload. Objectives: This study investigated the risk factors contributing to adverse event during unscheduled early revisit to Emergency Department Hospital Universiti Sains Malaysia. Methods: A retrospective cohort study was conducted from January 2014 to January 2015 to character the nature of unscheduled early revisits to Emergency Department Hospital Universiti Sains Malaysia. It included all patients 18 years old and above, revisited emergency department within 9 days post discharge from emergency department. Results: Data were collected from 492 case records. The rate of emergency department unplanned revisits within 9 days of previous emergency department discharge was 0.66% for the study period. Risk factors for revisit included advance age, pre-existing co-morbidities, duration spent during first emergency department visit and health care system–related error. The independent predictors of morbidity were diabetes mellitus (odds ratio, 2.07; 95% confidential interval, 1.08–3.96), respiratory disease (odds ratio, 2.42; 95% confidential interval, 1.18–4.98), gastrointestinal disease (odds ratio, 5.93; 95% confidential interval: 1.29, 27.35), nervous system disease (odds ratio, 4.65; 95% confidential interval: 1.27, 17.02), duration spent more than 6 h during first emergency department visit (odds ratio, 3.05; 95% confidential interval: 1.53, 6.07), and medical error leading to admission (odds ratio, 8.85; 95% confidential interval: 4.43, 17.67). The overall mortality rate was 0.2% (1/492). Conclusion: Emergency department physicians need to be extra vigilant when managing patients with risk factors, particularly the modifiable risk factors, to curb emergency department revisit.
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Affiliation(s)
- Siew Ling Loi
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Mohd Hashairi Hj Fauzi
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Abu Yazid Md Noh
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
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18
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Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform 2018; 9:248-260. [PMID: 29642247 DOI: 10.1055/s-0038-1641594] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Clinical decision support (CDS) embedded into the electronic health record (EHR), is a potentially powerful tool for institution of antimicrobial stewardship programs (ASPs) in emergency departments (EDs). However, design and implementation of CDS systems should be informed by the existing workflow to ensure its congruence with ED practice, which is characterized by erratic workflow, intermittent computer interactions, and variable timing of antibiotic prescription. OBJECTIVE This article aims to characterize ED workflow for four provider types, to guide future design and implementation of an ED-based ASP using the EHR. METHODS Workflow was systematically examined in a single, tertiary-care academic children's hospital ED. Clinicians with four roles (attending, nurse practitioner, physician assistant, resident) were observed over a 3-month period using a tablet computer-based data collection tool. Structural observations were recorded by investigators, and classified using a predetermined set of activities. Clinicians were queried regarding timing of diagnosis and disposition decision points. RESULTS A total of 23 providers were observed for 90 hours. Sixty-four different activities were captured for a total of 6,060 times. Among these activities, nine were conducted at different frequency or time allocation across four roles. Moreover, we identified differences in sequential patterns across roles. Decision points, whereby clinicians then proceeded with treatment, were identified 127 times. The most common decision points identified were: (1) after/during examining or talking to patient or relative; (2) after talking to a specialist; and (3) after diagnostic test/image was resulted and discussed with patient/family. CONCLUSION The design and implementation of CDS for ASP should support clinicians in various provider roles, despite having different workflow patterns. The clinicians make their decisions about treatment at different points of overall care delivery practice; likewise, the CDS should also support decisions at different points of care.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Danny T Y Wu
- Department of Biomedical Informatics and Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States
| | - Katia Hannah
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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19
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Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med 2018; 54:402-409. [DOI: 10.1016/j.jemermed.2017.12.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/22/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
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20
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Alcaraz-Martínez J, Aranaz-Andrés JM, Cantero-Sandoval A, Piñera-Salmerón P, Mas-Luzón J, Serrano-Martínez JA, González Garro E. [Use of complementary tests in emergencies and their relation with patient safety incidents]. J Healthc Qual Res 2018. [PMID: 29534933 DOI: 10.1016/j.cali.2018.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To analyse the use of complementary tests and their relationship with safety incidents in hospital emergency departments. METHODOLOGY An analysis was performed on 935 patients seen in the 9 hospital emergency departments. The source of data used for the detection of incidents were: emergency department clinical record and reports, together with face-to-face observation in the department, plus a telephone survey of the patient or family member at one week after the care. Statistical tests used: The Student t test for quantitative variables, Chi squared test for qualitative variables, and the ANOVA test. RESULTS A peripheral venous catheter was used in 397 patients (42.4% (95% CI; 39.3-45.5%)), with a variability with significant differences between hospitals (P<.01), with a range of use from 37% to 81.8%. It was also observed that in 23.4% (95% CI; 19.2-27.6%) of the cases, the catheter was not used after the first blood draw. Radiological tests were requested for 351 patients, 37.7% (95% CI; 34.6-40.8%), also with significant differences between hospitals (P<.01), ranging from 24.6 to 65, 1%. Incidents were detected in 95 (10.2%) patients (95% CI; 8.3-12.1%) in the all the study centres. A higher proportion of safety incidents have been observed in patients where peripheral venous catheter has been used (12.8%) than in those in whom they had not been used (8.5%) (P=.03), as well as in patients on whom an x-ray was requested (12.8%) compared to those who did not (8.64%) (P=.04). A longer stay was also observed in cases with an incident (mean 248.9minutes) than in those where there were none (mean 164.1minutes) (P<.001). No statistically significant differences were found in the other parameters studied. CONCLUSION A relationship was observed between the use of a peripheral venous catheter (many of them without use) and radiological tests and the occurrence of safety incidents in the Emergency Departments.
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Affiliation(s)
- J Alcaraz-Martínez
- Unidad de Calidad y Servicio de Urgencias, Hospital Universitario J.M. Morales Meseguer, Murcia, España.
| | - J M Aranaz-Andrés
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, Centro de Investigación Biomédica enRed en Epidemiología y Salud Pública (CIBERESP), Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España
| | - A Cantero-Sandoval
- Servicio de Urgencias, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - J Mas-Luzón
- Servicio de Urgencias, Hospital Universitario J.M. Morales Meseguer, Murcia, España
| | - J A Serrano-Martínez
- Servicio de Urgencias, Hospital Universitario J.M. Morales Meseguer, Murcia, España
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21
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Sills MR, Macy ML, Kocher KE, Sabbatini AK. Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children. Acad Emerg Med 2018; 25:283-292. [PMID: 28960666 DOI: 10.1111/acem.13324] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/26/2017] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit. METHODS This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission). RESULTS Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission. CONCLUSIONS Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.
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Affiliation(s)
- Marion R. Sills
- Departments of Pediatrics and Emergency Medicine and the Adult and Child Consortium for Outcomes Research and Delivery Science University of Colorado School of Medicine and Children's Hospital Colorado (MRS) AuroraCO
| | - Michelle L. Macy
- Department of Pediatrics University of Michigan Ann Arbor MI
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Child Health Evaluation and Research University of Michigan Ann Arbor MI
| | - Keith E. Kocher
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Amber K. Sabbatini
- Division of Emergency Medicine University of Washington Harborview Medical Center Seattle WA
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22
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Noori O, Batra S, Shetty A, Steinbeck K. Adolescent presentations to an adult hospital emergency department. Emerg Med Australas 2017; 29:539-544. [PMID: 28766858 DOI: 10.1111/1742-6723.12842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 06/06/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Age-related policies allow adolescents to access paediatric and adult EDs. Anecdotally, paediatric and adult EDs report challenges when caring for older and younger adolescents, respectively. Our aim was to describe the characteristics of an adolescent population attending an adult ED, co-located with a tertiary paediatric ED. METHODS The Westmead Hospital ED database was accessed for 14.5-17.9 years old presentations between January 2010 and December 2012. Patient diagnosis coding (SNOMED) was converted to ICD-10. De-identified data were transferred into Microsoft Excel with analysis performed using spss V22. RESULTS There were 5718 presentations made to the Westmead Hospital, Sydney, Australia ED by 4450 patients, representing 3.3% (95% CI 3.2-3.4) of total visits from all patients 14.5 years and above. The mean age of the sample was 16.6 years (male 51.8%). Presentations triaged as level 4 or 5 represented 61.0% (95% CI 58.7-61.3) of visits. The proportion of patients who did not wait to receive care was 13.8% (95% CI 12.9-14.7), which was significantly higher than adult rates (P < 0.01). There were 279 unscheduled return visits (visits made <72 h of discharge) representing 4.9% (95% CI 4.4-5.8) of all presentations. Injury was the most common diagnosis (30.2%, 95% CI 28.8-31.6). Chronic physical illness and alcohol-related visits comprised 2.1% (95% CI 1.7-2.5) and 0.8% (95% CI 0.6-1.0) of adolescent presentations, respectively. CONCLUSION Contrary to reported staff perceptions, adolescent chronic physical illness presentations were not a major burden. Alcohol was likely under-recorded as a contributing factor to presentations.
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Affiliation(s)
- Omar Noori
- Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Shweta Batra
- Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Amith Shetty
- Department of Emergency Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,NHMRC Centre for Research Excellence in Critical Infection, Westmead Millennium Institute, Sydney, New South Wales, Australia
| | - Katharine Steinbeck
- Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Paediatrics and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
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23
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Abstract
BACKGROUND Pediatric interhospital transfers are an economic burden to the health care, especially when deemed unnecessary. Physicians may be unaware of the cost implications of pediatric emergency transfers. A cost analysis may be relevant to reduce cost. OBJECTIVE To characterize children transferred from outlying emergency departments (EDs) to pediatric ED (PED) with a specific focus on transfers who were discharged home in 12 hours or less after transfer without intervention in PED and analyze charges associated with them. METHODS Charts of 352 patients (age, 0-18 years) transferred from 31 outlying EDs to PED during July 2009 to June 2010 were reviewed. Data were collected on the range, unit charge and volume of services provided in PED, length of stay, and final disposition. The average charge per patient transfer is calculated based on unit charge times total service units per 1000 patients per year and divided by 1000. Hospital charges were divided into fixed and variable. RESULTS Of 352 patients transferred, 108 (30.7%) were admitted to pediatric inpatient service, 42 (11.9%) to intensive care; 36 (10.2%) went to the operating room, and 166 (47.2%) were discharged home. The average hospital charge per transfer was US $4843. Most (89%) of the charges were fixed, and 11% were variable. One hundred one (28.7%) patients were discharged home from PED in 12 hours or less without intervention. The hospital charges for these transfers were US $489,143. CONCLUSIONS Significant number of transfers was discharged 12 hours or less without any additional intervention in PED. Fixed charges contribute to majority of total charges. Cost saving can be achieved by preventing unnecessary transfer.
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24
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Clark LN, Benda NC, Hegde S, McGeorge NM, Guarrera-Schick TK, Hettinger AZ, LaVergne DT, Perry SJ, Wears RL, Fairbanks RJ, Bisantz AM. Usability evaluation of an emergency department information system prototype designed using cognitive systems engineering techniques. APPLIED ERGONOMICS 2017; 60:356-365. [PMID: 28166896 PMCID: PMC5377444 DOI: 10.1016/j.apergo.2016.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 12/19/2016] [Accepted: 12/23/2016] [Indexed: 06/06/2023]
Abstract
This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the display's ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working.
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Affiliation(s)
- Lindsey N Clark
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, Washington D.C., USA
| | - Natalie C Benda
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, Washington D.C., USA; Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA
| | - Sudeep Hegde
- Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA
| | - Nicolette M McGeorge
- Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA
| | | | - A Zachary Hettinger
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, Washington D.C., USA; Department of Emergency Medicine, Georgetown University School of Medicine, Washington D.C., USA
| | - David T LaVergne
- Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA
| | - Shawna J Perry
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Robert L Wears
- Department of Emergency Medicine, University of Florida, Gainesville, FL, USA; Clinical Safety Research Unit, Imperial College London, London, UK
| | - Rollin J Fairbanks
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, MedStar Health, Washington D.C., USA; Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA; Department of Emergency Medicine, Georgetown University School of Medicine, Washington D.C., USA
| | - Ann M Bisantz
- Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA.
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25
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Hosford DA, Lai EH, Riley JH, Xu CF, Danoff TM, Roses AD. Pharmacogenetics to Predict Drug-Related Adverse Events. Toxicol Pathol 2016; 32 Suppl 1:9-12. [PMID: 15209398 DOI: 10.1080/01926230490424743] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Identification of reliable markers to predict drug-related adverse events (DRAEs) is an important goal of the pharmaceutical industry and others within the healthcare community. We have used genetic polymorphisms, including the most frequent source of variation (single nucleotide polymorphisms, SNPs) in the human genome, in pharmacogenetic approaches designed to predict DRAEs. Three studies exemplify the principles of using polymorphisms to identify associations in progressively larger genomic regions: polymorphic repeats within the UDP-glucuronysltransferase I (UGT1A1) gene in patients experiencing hyperbilirubinemia after administration of tranilast, an experimental drug to prevent re-stenosis following coronary revascularization; high linkage disequilibrium within the Apolipoprotein E (ApoE) gene in patients with Alzheimer Disease (AD); and the polymorphic variant HLA-B57 in patients with hypersensitivity reaction after administration of abacavir, a nucleoside reverse transcriptase inhibitor for the treatment of HIV. Together, these studies demonstrate in a stepwise manner the feasibility of using pharmacogenetic approaches to predict DRAEs.
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Affiliation(s)
- David A Hosford
- Department of Genetics Research, GlaxoSmithKline R&D, Research Triangle Park, North Carolina 27709, USA.
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Maio V, Goldfarb NI, Keroack M, Browne RC, Nash DB. Outpatient Quality Improvement in Academic Faculty Practice Plans: Does it Exist? Am J Med Qual 2016; 19:235-41. [PMID: 15620074 DOI: 10.1177/106286060401900602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to (a) investigate the extent to which academic faculty practice plans (FPPs) are currently involved in ambulatory care quality improvement (QI), (b) describe the structure of QI initiatives at outpatient FPPs, and (c) delineate facilitators and barriers to development of FPP outpatient QI initiatives. Members of the Steering Committee of the Group Practice Council of the University HealthSystem Consortium (UHC), representing the leadership of 88 FPPs, were asked to respond to a 38-item Web-based questionnaire during February and March 2003. The survey elicited information on the organizational characteristics of FPPs, their current degree of engagement in outpatient QI activities, and factors driving interest and barriers impeding efforts to conduct outpatient QI initiatives. Descriptive statistics for all variables of interest were performed. Responses were received from 33 participants believed to represent at least 28 of the total 88 FPP members of the UHC. Nearly all respondents indicated that some types of outpatient QI initiatives were currently taking place in their FPP. However, only 12% of respondents met 4 or more of the 6 criteria deemed to be essential to having a robust outpatient QI program. Among key QI indicators, one third of respondents reported that their FPP had a separate and distinct outpatient quality committee, and some one fifth had a budget for outpatient QI or financial incentives for outpatient clinics to engage in QI (or both). The majority of respondents stated that at least some departments in their FPP were collecting quality data. Most respondents reported that patient safety and external demand for outpatient QI were the "more important" factors driving QI efforts, whereas lack of human resources and other resources were the "more significant" barriers hindering QI initiatives. The results of the study suggest that, although FPPs showed a strong interest in outpatient QI initiatives, FPPs' efforts are still in an infancy phase and lag far behind inpatient performance measurement activities. Without appropriate resources, it appears unlikely that FPPs will be able to move the agenda forward to develop a quality culture and robust program of self-assessment and improvement in the outpatient setting.
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Affiliation(s)
- Vittorio Maio
- Department of Health Policy, Jefferson Medical College, Philadelphia, PA 19107, USA.
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Arnold DH, Sills MR, Walsh CG. The asthma prediction rule to decrease hospitalizations for children with asthma. Curr Opin Allergy Clin Immunol 2016; 16:201-9. [PMID: 26918532 PMCID: PMC5380119 DOI: 10.1097/aci.0000000000000259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of the present review was to discuss the challenges around clinical decision-making for hospitalization of children with acute asthma exacerbations and the development, internal validation, and future potential of the asthma prediction rule (APR) to provide meaningful clinical decision-support that might decrease unnecessary hospitalizations. RECENT FINDINGS The APR was developed and internally validated using predictor variables available before treatment in the emergency department, and performed well to predict 'need-for-hospitalization.' Oxygen saturation on room air and expiratory phase prolongation were most strongly associated with need-for-hospitalization. SUMMARY Research on prediction rules in pediatric asthma is rare. We developed and internally validated the APR using clinically intuitive predictor variables that are available at the bedside. Before incorporation into electronic decision-support the APR must undergo external validation and an impact analysis to determine if use of this tool will change clinician behavior and improve patient outcomes.
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Affiliation(s)
- Donald H Arnold
- aDivision of Emergency Medicine, Department of Pediatrics and Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee bSection of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado cDepartment of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes. CLIN NURSE SPEC 2016; 30:28-37. [DOI: 10.1097/nur.0000000000000169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McGeorge N, Hegde S, Berg RL, Guarrera-Schick TK, LaVergne DT, Casucci SN, Hettinger AZ, Clark LN, Lin L, Fairbanks RJ, Benda NC, Sun L, Wears RL, Perry S, Bisantz A. Assessment of Innovative Emergency Department Information Displays in a Clinical Simulation Center. JOURNAL OF COGNITIVE ENGINEERING AND DECISION MAKING 2015; 9:329-346. [PMID: 27974881 PMCID: PMC5152766 DOI: 10.1177/1555343415613723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The objective of this work was to assess the functional utility of new display concepts for an emergency department information system created using cognitive systems engineering methods, by comparing them to similar displays currently in use. The display concepts were compared to standard displays in a clinical simulation study during which nurse-physician teams performed simulated emergency department tasks. Questionnaires were used to assess the cognitive support provided by the displays, participants' level of situation awareness, and participants' workload during the simulated tasks. Participants rated the new displays significantly higher than the control displays in terms of cognitive support. There was no significant difference in workload scores between the display conditions. There was no main effect of display type on situation awareness, but there was a significant interaction; participants using the new displays showed improved situation awareness from the middle to the end of the session. This study demonstrates that cognitive systems engineering methods can be used to create innovative displays that better support emergency medicine tasks, without increasing workload, compared to more standard displays. These methods provide a means to develop emergency department information systems-and more broadly, health information technology-that better support the cognitive needs of healthcare providers.
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Affiliation(s)
- Nicolette McGeorge
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - Sudeep Hegde
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - Rebecca L Berg
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - Theresa K Guarrera-Schick
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - David T LaVergne
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - Sabrina N Casucci
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - A Zachary Hettinger
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, and Department of Emergency Medicine, Georgetown University
| | - Lindsey N Clark
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation
| | - Li Lin
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - Rollin J Fairbanks
- National Center for Human Factors in Healthcare, MedStar Institute for Innovation, and Department of Industrial and Systems Engineering, University at Buffalo, State University of New York, and Department of Emergency Medicine, Georgetown University, and Simulation Training & Education Lab (SiTEL), MedStar Health
| | - Natalie C Benda
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York, and National Center for Human Factors in Healthcare, MedStar Institute for Innovation
| | - Longsheng Sun
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
| | - Robert L Wears
- Department of Emergency Medicine, University of Florida, and Clinical Safety Research Unit, Imperial College London
| | - Shawna Perry
- Department of Emergency Medicine, University of Florida
| | - Ann Bisantz
- Department of Industrial and Systems Engineering, University at Buffalo, State University of New York
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Ramlakhan S, Qayyum H, Burke D, Brown R. The safety of emergency medicine. Emerg Med J 2015; 33:293-9. [PMID: 26531857 DOI: 10.1136/emermed-2014-204564] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 10/07/2015] [Indexed: 11/03/2022]
Abstract
The patient safety movement has been active for over a decade, but the issue of patient safety in emergency care and the emergency department (ED) has only recently been brought into the forefront. The ED environment has traditionally been considered unsafe, but there is little data to support this assertion. This paper reviews the literature on patient safety and highlights the challenges associated with using the current evidence base to inform practice due to the variability in methods of measuring safety. Studies looking at safety in the ED report low rates for adverse events ranging from 3.6 to 32.6 events per 1000 attendances. The wide variation in reported rates on adverse events reflects the significant differences in methods of reporting and classifying safety incidents and harm between departments; standardisation in the ED context is urgently required to allow comparisons to be made between departments and to quantify the impact of specific interventions. We outline the key factors in emergency care which may hinder the provision of safer care and consider solutions which have evolved or been proposed to identify and mitigate against harm. Interventions such as team training, telephone follow-up, ED pharmacist interventions and rounding, all show some evidence of improving safety in the ED. We further highlight the need for a collaborative whole system approach as almost half of safety incidents in the ED are attributable to external factors, particularly those related to information flow, crowding, demand and boarding.
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Affiliation(s)
- Shammi Ramlakhan
- Sheffield Teaching Hospitals, Sheffield, UK Sheffield Children's Hospital, Sheffield, UK
| | | | - Derek Burke
- Sheffield Children's Hospital, Sheffield, UK
| | - Ruth Brown
- Imperial Healthcare NHS Trust, London, UK
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Broder JS, Fox JW, Milne J, Theiling BJ, White A. Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action. Emerg Med J 2015; 33:260-7. [DOI: 10.1136/emermed-2015-204821] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 09/26/2015] [Indexed: 11/04/2022]
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In Situ Medical Simulation Investigation of Emergency Department Procedural Sedation With Randomized Trial of Experimental Bedside Clinical Process Guidance Intervention. Simul Healthc 2015; 10:146-53. [DOI: 10.1097/sih.0000000000000083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Fisher JD, Freeman K, Clarke A, Spurgeon P, Smyth M, Perkins GD, Sujan MA, Cooke MW. Patient safety in ambulance services: a scoping review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03210] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BackgroundThe role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.ObjectiveTo identify and map available evidence relating to patient safety when using ambulance services.DesignMixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.Setting and participantsAmbulance services, their staff and service users in UK.Data sourcesA wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.Review methodsData were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.ResultsWe identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.ConclusionPatient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne D Fisher
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Karoline Freeman
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Aileen Clarke
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Peter Spurgeon
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Mike Smyth
- West Midlands Ambulance Service, Millennium Point, Waterfront Business Park, Brierley Hill, West Midlands, UK
| | - Gavin D Perkins
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | | | - Matthew W Cooke
- Department of Health Sciences, Warwick Medical School, Coventry, UK
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Jenab Y, Haghani S, Jalali A, Darabi F. Unscheduled Return Visits and Leaving the Chest Pain Unit Against Medical Advice. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e18320. [PMID: 26082847 PMCID: PMC4464376 DOI: 10.5812/ircmj.17(5)2015.18320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 09/18/2014] [Accepted: 10/06/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rate of Unscheduled Return Visits (URVs) to the Emergency Department has been considered as a key indicator for evaluating the quality of the Emergency Department care for decades. A higher rate of URVs can have a negative impact on the quality of health care. Investigations of the reasons for these returns have indicated that many of these visits can be preventable. OBJECTIVES Given that there are no clear findings about the frequency and reasons for 72 hours URVs to the Chest Pain Unit (CPU), in the present study, we investigated the causes of 72 hours URVs to our CPU in order to find out the inadequacies, and propose preventive strategies. PATIENTS AND METHODS This research was a single-center retrospective case control study in the setting of CPU of Tehran Heart Center (a 460-bed, tertiary-care teaching hospital), Tehran, Iran. The medical records of the patients who were presented to our CPU with the chief complaint of chest pain between December 28(th), 2010 and February 28(th), 2011 were reviewed. Of the 6247 eligible patients, forty-nine URVs that fulfilled our criteria were identified. The control group consisted of 196 patients who did not return to the Emergency Department during our study period. RESULTS Patient-related factors accounted for most 72 hours URVs (49%). Multivariable analysis revealed that in our CPU, leaving Against medical advice was the most important predictor for 72 hours URVs (P value < 0.001). Additionally, male sex, history of hypertension, first-visit disposition to observation unit and age were the other factors associated with URVs. CONCLUSIONS Considering that the most frequent reason for our URVs was patient-related factors, where all cases had left the CPU Against Medical Advice (AMA) during their first attendance, we recommend that further appropriate strategies be devised to prevent leaving against medical advice.
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Affiliation(s)
- Yaser Jenab
- General Cardiology Department, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Shima Haghani
- Clinical Research Department, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Arash Jalali
- Clinical Research Department, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Farzad Darabi
- Clinical Research Department, Tehran University of Medical Sciences, Tehran, IR Iran
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Reznek MA, Kotkowski KA, Arce MW, Jepson ZK, Bird SB, Darling CE. Patient safety incident capture resulting from incident reports: a comparative observational analysis. BMC Emerg Med 2015; 15:6. [PMID: 25880446 PMCID: PMC4404244 DOI: 10.1186/s12873-015-0032-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs. METHODS A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups. RESULTS 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p < 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs. CONCLUSION HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. Further research is warranted to develop effective strategies to improve the utility of incident reports from both HCPs and non-HCPs.
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Affiliation(s)
- Martin A Reznek
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Kevin A Kotkowski
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Michael W Arce
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Zachary K Jepson
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Steven B Bird
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Chad E Darling
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
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Sin B, Yee L, Claudio-Saez M, Halim Q, Marshall L, Hayes-Quinn M. Implementation of a 24-hour pharmacy service with prospective medication review in the emergency department. Hosp Pharm 2015; 50:134-8. [PMID: 25717209 DOI: 10.1310/hpj5002-134] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND It is reported that more than 128 million patients are seen in emergency departments (EDs) annually. Patient overcrowding had been associated with an increased occurrence of medication errors. PURPOSE Due to increased patient volume and the need for improved patient safety, a 24-hour pharmacy service was established for our institution's ED. The purpose of the study is to quantify and demonstrate the impact of a 24-hour pharmacy service in an urban ED. METHODS This was a retrospective descriptive study conducted at a regional level 1 trauma center. The study period occurred between December 2012 and July 2013. The following variables were quantified and analyzed: number of medication orders reviewed, number of intravenous medications compounded, and number of clinical interventions that were recommended by the ED pharmacy team (EDPT) and accepted by ED clinicians. RESULTS A total of 3,779 medication orders were reviewed by the EDPT. Of these orders, 3,482 (92%) were prospectively reviewed. A total of 3,068 (81.2%) and 711 (18.8%) orders were reviewed for the adult and pediatric ED, respectively. During the study period, the EDPT procured 549 intravenous admixtures and conducted 642 clinical interventions. Most of the interventions involved providing drug information for physicians and nurses (45.9%), adjusting drug dosages (21.1%), and recommending antimicrobial therapy (15.1%). CONCLUSION The implementation of a 24-hour pharmacy service at our institution was an innovative practice that increased the role of pharmacists in the ED. The EDPT conducted prospective medication review, procured intravenous admixtures from a sterile environment, and provided therapeutic recommendations for the ED interdisciplinary team.
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Affiliation(s)
- Billy Sin
- Emergency Medicine Clinical Pharmacist, Brookdale University Hospital Medical Center , Brooklyn, New York
| | - Linda Yee
- Clinical Pharmacist, Internal Medicine, Brookdale University Hospital Medical Center , Brooklyn, New York
| | - Maria Claudio-Saez
- Assistant Director, Pharmacy Services, Brookdale University Hospital Medical Center , Brooklyn, New York
| | - Qazi Halim
- Director, Pharmacy Services, Brookdale University Hospital Medical Center , Brooklyn, New York
| | - Lewis Marshall
- Chairman, Emergency Medicine, Brookdale University Hospital Medical Center , Brooklyn, New York
| | - Mary Hayes-Quinn
- Director, Emergency Medicine Nursing Services, Brookdale University Hospital Medical Center , Brooklyn, New York
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Källberg AS, Göransson KE, Florin J, Östergren J, Brixey JJ, Ehrenberg A. Contributing factors to errors in Swedish emergency departments. Int Emerg Nurs 2014; 23:156-61. [PMID: 25434782 DOI: 10.1016/j.ienj.2014.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/25/2014] [Accepted: 10/05/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The Emergency Department (ED) is a complex and dynamic environment, often resulting in a somewhat uncontrolled and unpredictable workload. Contributing factors to errors in health care and in the ED are largely related to communication breakdowns. Moreover, the ED work environment is predisposed to multitasking, overcrowding and interruptions. These factors are assumed to have a negative impact on patient safety. Reported errors from care providers are mainly related to diagnostic procedures in Swedish EDs. However, there is a lack of knowledge and national oversight regarding contributing factors. The aim of this study was therefore to describe contributing factors in regards to errors occurring in Swedish EDs. METHOD Descriptive design based on registry data from the Lex Maria database of the Swedish National Board of Health and Welfare. RESULTS The results indicate that factors contributing to errors in Swedish EDs are multifactorial in nature. The most common contributing factor was human error followed by factors in the local ED environment and teamwork failure. CONCLUSION Factors contributing to ED errors were multifactorial and included both organizational and teamwork failure in which human error was implicated. To reduce errors, further research is needed to develop methods that disclose latent working conditions such as high workload and interruptions. Patient safety research needs to include understanding of human behaviour in complex organizational systems and the impact of working conditions on patient safety and quality of care.
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Affiliation(s)
- Ann-Sofie Källberg
- Department of Medicine Solna, Karolinska Institutet, Solna, Sweden; Department of Emergency Medicine, Falun Hospital, Falun, Sweden.
| | - Katarina E Göransson
- Department of Medicine Solna, Karolinska Institutet, Solna, Sweden; Department of Emergency Medicine, Karolinska University Hospital, Solna, Sweden
| | - Jan Florin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Jan Östergren
- Department of Medicine Solna, Karolinska Institutet, Solna, Sweden; Department of Emergency Medicine, Karolinska University Hospital, Solna, Sweden
| | - Juliana J Brixey
- School of Biomedical Informatics, University of Texas, Houston, Texas, USA
| | - Anna Ehrenberg
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
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Griffey RT, Kennedy SK, D'Agostino McGowan L, McGownan L, Goodman M, Kaphingst KA. Is low health literacy associated with increased emergency department utilization and recidivism? Acad Emerg Med 2014; 21:1109-15. [PMID: 25308133 PMCID: PMC4626077 DOI: 10.1111/acem.12476] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 04/25/2014] [Accepted: 06/19/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to determine whether patients with low health literacy have higher emergency department (ED) utilization and higher ED recidivism than patients with adequate health literacy. METHODS The study was conducted at an urban academic ED with more than 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross-sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (S-TOFHLA) and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis and retaining those significant at an alpha of 0.05 in the final model. RESULTS Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. CONCLUSIONS In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days.
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Affiliation(s)
- Richard T Griffey
- The Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
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Jepson ZK, Darling CE, Kotkowski KA, Bird SB, Arce MW, Volturo GA, Reznek MA. Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process. BMC Emerg Med 2014; 14:20. [PMID: 25106803 PMCID: PMC4132274 DOI: 10.1186/1471-227x-14-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/24/2014] [Indexed: 11/18/2022] Open
Abstract
Background Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives. Methods An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators’ experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted. Results In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm. Conclusion Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction.
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Affiliation(s)
| | | | | | | | | | | | - Martin A Reznek
- Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
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Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med 2014; 6:45-55. [PMID: 27147879 PMCID: PMC4753984 DOI: 10.2147/oaem.s64174] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, bar-coding systems, medication reconciliation, standardizing medication-use processes, education, and emergency-medicine clinical pharmacists. Special consideration also needs to be given to the development of strategies for the pediatric population, as they can be at an elevated risk of harm. Regardless of the strategies implemented, the prevention of medication errors begins and ends with the development of a culture that promotes the reporting of medication errors, and a systematic, nonpunitive approach to their elimination.
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Affiliation(s)
- Kyle A Weant
- North Carolina Public Health Preparedness and Response, North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Abby M Bailey
- University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Stephanie N Baker
- University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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Zeraatchi A, Talebian MT, Nejati A, Dashti-Khavidaki S. Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments. J Res Pharm Pract 2014; 2:118-22. [PMID: 24991618 PMCID: PMC4076918 DOI: 10.4103/2279-042x.122384] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various medical conditions. Due to a large number of patients with complex diseases, speed and complexity of medication use, working in under-staffing and crowded environment, medication errors are commonly perpetrated by emergency care providers. This study was designed to evaluate the incidence of medication errors among patients attending to an ED in a teaching hospital in Iran. Methods: In this cross-sectional study, a total of 500 patients attending to ED were randomly assessed for incidence and types of medication errors. Some factors related to medication errors such as working shift, weekdays and schedule of the educational program of trainee were also evaluated. Findings: Nearly, 22% of patients experienced at least one medication error. The rate of medication errors were 0.41 errors per patient and 0.16 errors per ordered medication. The frequency of medication errors was higher in men, middle age patients, first weekdays, night-time work schedules and the first semester of educational year of new junior emergency medicine residents. More than 60% of errors were prescription errors by physicians and the remaining were transcription or administration errors by nurses. More than 35% of the prescribing errors happened during the selection of drug dose and frequency. The most common medication errors by nurses during the administration were omission error (16.2%) followed by unauthorized drug (6.4%). Most of the medication errors happened for anticoagulants and thrombolytics (41.2%) followed by antimicrobial agents (37.7%) and insulin (7.4%). Conclusion: In this study, at least one-fifth of the patients attending to ED experienced medication errors resulting from multiple factors. More common prescription errors happened during ordering drug dose and frequency. More common administration errors included dug omission or unauthorized drug.
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Affiliation(s)
- Alireza Zeraatchi
- Department of Emergency Medicine, Tehran University of Medical Science, Tehran, Iran
| | | | - Amir Nejati
- Department of Emergency Medicine, Tehran University of Medical Science, Tehran, Iran
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Reznek MA, Barton BA. Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual Health Care 2014; 26:278-86. [DOI: 10.1093/intqhc/mzu045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hsia RY, Asch SM, Weiss RE, Zingmond D, Gabayan G, Liang LJ, Han W, McCreath H, Sun BC. Is emergency department crowding associated with increased "bounceback" admissions? Med Care 2013; 51:1008-14. [PMID: 24036997 DOI: 10.1097/mlr.0b013e3182a98310] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions. METHODS We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission. RESULTS We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00). CONCLUSIONS Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.
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Affiliation(s)
- Renee Y Hsia
- *Department of Emergency Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco †VA Palo Alto Health Care System, Center for Healthcare Evaluation, Menlo Park ‡Department of Biostatistics, UCLA Fielding School of Public Health §Department of Medicine ∥Department of Medicine, Division of Geriatrics, University of California, Los Angeles, Los Angeles, CA ¶Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
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Abstract
The circumstances that led to the death of Libby Zion in 1984 prompted national discussions about the impact of resident fatigue on patient outcomes. Nearly 30 years later, national duty hour reforms largely motivated by patient safety concerns have demonstrated a negligible impact of duty hour reductions on patient mortality. We suggest that the lack of an impact of duty hour reforms on patient mortality is due to a different medical landscape today than existed in 1984. Improvements in quality of care made possible by computerized order entry, automated medication checks, inpatient pharmacists, and increased resident supervision have, among other systemic changes, diminished the adverse impact that resident fatigue is able to have on patient outcomes. Given this new medical landscape, advocacy towards current and future duty hour reforms may be best justified by evidence of the impact of duty hour reform on resident wellbeing, education, and burnout.
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Affiliation(s)
- Anupam B. Jena
- />Department of Health Care Policy, Harvard Medical School, Boston, MA USA
- />Massachusetts General Hospital, Boston, MA USA
- />National Bureau of Economic Research, Cambridge, MA USA
| | - Vinay Prasad
- />Medical Oncology Branch, National Cancer Institute, National Institutes of Health, 10 Center Dr. 10/12N226, Bethesda, MD 20892 USA
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Lecoanet A, Sellier E, Carpentier F, Maignan M, Seigneurin A, François P. Experience feedback committee in emergency medicine: a tool for security management. Emerg Med J 2013; 31:894-8. [PMID: 23964063 PMCID: PMC4215281 DOI: 10.1136/emermed-2013-202767] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Emergency departments are high-risk structures. The objective was to analyse the functioning of an experience feedback committee (EFC), a security management tool for the analysis of incidents in a medical department. METHODS We conducted a descriptive study based on the analysis of the written documents produced by the EFC between November 2009 and May 2012. We performed a double analysis of all incident reports, meeting minutes and analysis reports. RESULTS During the study period, there were 22 meetings attended by 15 professionals. 471 reported incidents were transmitted to the EFC. Most of them (95%) had no consequence for the patients. Only one reported incident led to the patient's death. 12 incidents were analysed thoroughly and the committee decided to set up 14 corrective actions, including eight guideline writing actions, two staff trainings, two resource materials provisions and two organisational changes. CONCLUSIONS The staff took part actively in the EFC. Following the analysis of incidents, the EFC was able to set up actions at the departmental level. Thus, an EFC seems to be an appropriate security management tool for an emergency department.
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Affiliation(s)
- André Lecoanet
- Pôle Santé Publique, Unité d'évaluation médicale, Centre Hospitalier Universitaire, Grenoble, France
| | - Elodie Sellier
- Pôle Santé Publique, Unité d'évaluation médicale, Centre Hospitalier Universitaire, Grenoble, France UJF-Grenoble 1/CNRS/TIMC-IMAG UMR 5525, Grenoble, France
| | | | - Maxime Maignan
- Département des urgences, Centre Hospitalier Universitaire, Grenoble, France
| | - Arnaud Seigneurin
- Pôle Santé Publique, Unité d'évaluation médicale, Centre Hospitalier Universitaire, Grenoble, France
| | - Patrice François
- Pôle Santé Publique, Unité d'évaluation médicale, Centre Hospitalier Universitaire, Grenoble, France UJF-Grenoble 1/CNRS/TIMC-IMAG UMR 5525, Grenoble, France
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Berg LM, Källberg AS, Göransson KE, Östergren J, Florin J, Ehrenberg A. Interruptions in emergency department work: an observational and interview study. BMJ Qual Saf 2013; 22:656-63. [DOI: 10.1136/bmjqs-2013-001967] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kianmehr N, Mofidi M, Saidi H, Hajibeigi M, Rezai M. What are Patients' Concerns about Medical Errors in an Emergency Department? Sultan Qaboos Univ Med J 2012; 12:86-92. [PMID: 22375263 DOI: 10.12816/0003092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 08/23/2011] [Accepted: 11/30/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Concerns about medical errors have recently increased. An understanding of how patients conceptualise medical error would help health care providers to allay safety concerns and increase patient satisfaction. The aim of this study was to evaluate patients' worries about medical errors and their relationship with patient characteristics and satisfaction. METHODS This descriptive cross-sectional study was done in the Emergency Department (ED) of a university hospital over a one week period in October 2008. A questionnaire was used to assess patients' worries about medical errors and their satisfaction levels both at an initial interview and by telephone 7 days after discharge. Data were gathered and analysed by χ2, t-tests and logistic regression. RESULTS Of 638 patients interviewed, 61.6% declared their satisfaction rate as good to excellent; (93 [14.6%] as poor; 152 [23.8%] as fair; 296 [46.4%] as good; 97 [15.2%] as excellent). A total of 48.3% of patients (44.5-52%, with confidence interval 95%) were concerned about the occurrence of at least one medical error. There was a clear relationship between the general satisfaction rate and having at least one concern about a medical error (Chi-square, P <0.001). CONCLUSION This study showed that many patients were concerned about medical errors during their emergency care. Due to the stressful situation in EDs, patients' safety and satisfaction could be improved by a better understanding of patient concerns, education of ED staff and an improvement in the patient-doctor relationship.
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Affiliation(s)
- Nahid Kianmehr
- Department of Internal Medicine, Tehran University of Medical Sciences, Iran, and Department of Internal Medicine, Hazrat e Rasool Akram Hospital, Tehran, Iran
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Paltved C, Musaeus P. Qualitative Research on Emergency Medicine Physicians: A Literature Review. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ijcm.2012.37a136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Arnold DH, Gebretsadik T, Abramo TJ, Hartert TV. Noninvasive testing of lung function and inflammation in pediatric patients with acute asthma exacerbations. J Asthma 2011; 49:29-35. [PMID: 22133263 DOI: 10.3109/02770903.2011.637599] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE There is limited information on performance rates for tests of lung function and inflammation in pediatric patients with acute asthma exacerbations. We sought to examine how frequently pediatric patients with acute asthma exacerbations could perform noninvasive lung function and exhaled nitric oxide (FE(NO)) testing and participant characteristics associated with successful performance. METHODS We studied a prospective convenience sample aged 5-17 years with acute asthma exacerbations in a pediatric emergency department. Participants attempted spirometry for percent predicted forced expiratory volume in 1 second (%FEV(1)), airway resistance (Rint), and FE(NO) testing before treatment. We examined overall performance rates and the associations of age, gender, race, and baseline acute asthma severity score with successful test performance. RESULTS Among 573 participants, age was (median [interquartile range]) 8.8 [6.8, 11.5] years, 60% were male, 57% were African-American, and 58% had Medicaid insurance. Tests were performed successfully by the following [n (%)]: full American Thoracic Society-European Respiratory Society criteria spirometry, 331 (58%); Rint, 561 (98%); and FE(NO), 354 (70% of 505 attempted test). Sixty percent with mild-moderate exacerbations performed spirometry compared to 17% with severe exacerbations (p = .0001). Participants aged 8-12 years (67%) were more likely to perform spirometry than those aged 5-7 years (48%) (OR = 2.23, 95% CI: 1.45-3.11) or 13-17 years (58%) (OR = 1.61, 95% CI: 1.00-2.59). CONCLUSIONS There is clinically important variability in performance of these tests during acute asthma exacerbations. The proportion of patients with severe exacerbations able to perform spirometry (17%) limits its utility. Almost all children with acute asthma can perform Rint testing, and further development and validation of this technology is warranted.
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Affiliation(s)
- Donald H Arnold
- Department of Pediatrics, Division of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
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