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Incidence and types of non-ideal care events in an emergency department
Abstract
To identify and characterise hazardous conditions in an Emergency Department (ED) using active surveillance.
This study was conducted in an urban, academic, tertiary care medical centre ED with over 45,000 annual adult visits. Trained research assistants interviewed care givers at the discharge of a systematically sampled group of patient visits across all shifts and days of the week. Care givers were asked to describe any part of the patient's care that they considered to be 'not ideal.' Reports were categorised by the segment of emergency care in which the event occurred and by a broad event category and specific event type. The occurrence of harm was also determined.
Surveillance was conducted for 656 h with 487 visits sampled, representing 15% of total visits. A total of 1180 care giver interviews were completed (29 declines), generating 210 non-duplicative event reports for 153 visits. Thirty-two per cent of the visits had at least one non-ideal care event. Segments of care with the highest percentage of events were: Diagnostic Testing (29%), Disposition (21%), Evaluation (18%) and Treatment (14%). Process-related delays were the most frequently reported events within the categories of medication delivery (53%), laboratory testing (88%) and radiology testing (79%). Fourteen (7%) of the reported events were associated with patient harm.
A significant number of non-ideal care events occurred during ED visits and involved failures in medication delivery, radiology testing and laboratory testing processes, and resulted in delays and patient harm.
... The included articles ( Table 2 and Table S3) were prospective, observational studies: seven prospective cohort studies [9,10,20,21,24,25,26,27] and one before-and-after interventional design [22,23,27]. Methodological quality was low to moderate with weaknesses in study group comparability, follow-up, and outcome ascertainment and reporting (Table 1). ...
... Particular weaknesses in outcome ascertainment and reporting included failure to clearly report methods used to determine AE causality, preventability and severity. Seven studies took place in urban, tertiary care academic hospitals in either Canada, the United States or Australia [9,10,21,24,25,26,27] and one study took place in a rural base hospital in Australia [22,23]. A total of 38,702 patients were included in the eight studies, with a median of 1219 patients (range 201 [25] to 20,500 [22,23]). ...
... A total of 38,702 patients were included in the eight studies, with a median of 1219 patients (range 201 [25] to 20,500 [22,23]). Four studies included only adults [10,24,25,26] and four enrolled adults and children [9,20,21,22,23,27]. ...
To systematically review the literature regarding the prevalence, preventability, severity and types of adverse events (AE) in the Emergency Department (ED).
We systematically searched major bibliographic databases, relevant journals and conference proceedings, and completed reference reviews of primary articles. Observational studies (cohort and case-control), quasi-experimental (e.g. before/after) studies and randomized controlled trials, were considered for inclusion if they examined a broad demographic group reflecting a significant proportion of ED patients and described the proportion of AE. Studies conducted outside of the ED setting, those examining only a subpopulation of patients (e.g. a specific entrance complaint or receiving a specific intervention), or examining only adverse drug events, were excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality with the Newcastle Ottawa Scale.
Our search identified 11,624 citations. Ten articles, representing eight observational studies, were included. Methodological quality was low to moderate with weaknesses in study group comparability, follow-up, and outcome ascertainment and reporting. There was substantial variation in the proportion of patients with AE related to ED care, ranging from 0.16% (n = 9308) to 6.0% (n = 399). Similarly, the reported preventability of AE ranged from 36% (n = 250) to 71% (n = 24). The most common types of events were related to management (3 studies), diagnosis (2 studies) and medication (2 studies).
The variability in findings and lack of high quality studies on AE in the high risk ED setting highlights the need for research in this area. Further studies with rigorous, standardized outcome assessment and reporting are required.
... Un enfermo que acuda a un SU y que sea atendido sin generar ninguna intervención se encuentra sometido a más del 35% de los riesgos recogidos en el documento. Estos datos coinciden también con los hallazgos descritos en la literatura al analizar la incidencia de EA en los SU y la hospitalización [5] [20] [22][23]. ...
Objective: To design and validate an emergency care risk map (RM) which can be used in all the Spanish emergency departments (ED).
... Most previous studies have included passive or self-reporting method for error detection, which is associated with an underestimation of harm and frequency of medical errors. Reported rates of medical errors in the ED vary from 18 [9] to 32 % [10]. ...
Background:
Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10 % of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED.
Design:
The CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6 % - 1584 patients will be included, 140 for each period in each center.
Discussion:
The CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors.
Trial registration:
Clinical Trials, NCT02356926.
... 10 A more recent ED interview study showed that 32% of 487 visits had at least 1 "nonideal" care event. 11 Traditional approaches to identifying and preventing the causes of errors (eg, root-cause analysis) are often passive and emphasize individual factors. 12 Active surveillance of frontline health care providers about systems factors that may cause errors is an innovative strategy for identifying correctable causes of errors. ...
We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs.
We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors. We also obtained surveys from 3,562 staff randomly selected from each ED; survey data were used to calculate average safety climate scores for each ED.
We identified 402 adverse events (incidence rate 4.1 per 100 patient visits; 95% confidence interval [CI] 3.7 to 4.5) and 532 near misses (incidence rate 5.4 per 100 patient visits; 95% CI 5.0 to 5.9). We judged 37% of the adverse events, and all of the near misses, to be preventable (errors); 33% of the near misses were intercepted. In multivariable models, better ED safety climate was not associated with fewer preventable adverse events (incidence rate ratio per 0.2-point increase in ED safety score 0.82; 95% CI 0.57 to 1.16) but was associated with more intercepted near misses (incidence rate ratio 1.79; 95% CI 1.06 to 3.03). We found no association between safety climate and violations of national treatment guidelines.
Among the 3 ED conditions studied, medical errors are relatively common, and one third of adverse events are preventable. Improved ED safety climate may increase the likelihood that near misses are intercepted.
Numerous challenges with the implementation, acceptance, and use of health IT are related to poor usability and a lack of integration of the technologies into clinical workflow, and have, therefore, limited the potential of these technologies to improve patient safety. We propose a definition and conceptual model of health IT workflow integration. Using interviews of 12 emergency department (ED) physicians, we identify 134 excerpts of barriers and facilitators to workflow integration of a human factors (HF)-based clinical decision support (CDS) implemented in the ED. Using data on these 134 barriers and facilitators, we distinguish 25 components of workflow integration of the CDS, which are described according to four dimensions of workflow integration: time, flow, scope of patient journey, and level. The proposed definition and conceptual model of workflow integration can be used to inform health IT design; this is the purpose of the proposed checklist that can help to ensure consideration of workflow integration during the development of health IT.
Background
Understanding adverse events among children treated in the emergency department (ED) offers an opportunity to improve patient safety by providing evidence of where to focus efforts in a resource-restricted environment.
Objective
To estimate the risk of adverse events, their type, preventability and severity, for children seen in a paediatric ED.
Methods
This prospective cohort study examined outcomes of patients presenting to a paediatric ED over a 1-year period. The primary outcome was the proportion of patients with an adverse event (harm to patient related to healthcare received) related to ED care within 3 weeks of their visit. We conducted structured telephone interviews with all patients and families over a 3-week period following their visit to identify flagged outcomes (such as repeat ED visits, worsening symptoms) and screened admitted patients’ health records with a validated trigger tool. For patients with flagged outcomes or triggers, three ED physicians independently determined whether an adverse event occurred.
Results
Of 1567 eligible patients, 1367 (87.2%) were enrolled and 1319 (96.5%) reached in follow-up. Median patient age was 4.34 years (IQR 1.5 to 10.57 years) and most (n=1281; 93.7%) were discharged. Among those with follow-up, 33 (2.5%, 95% CI 1.8% to 3.5%) suffered an adverse event related to ED care. None experienced more than one event. Twenty-nine adverse events (87.9%, 95% CI 72.7% to 95.2%) were deemed preventable. The most common types of adverse events (not mutually exclusive) were management issues (51.5%), diagnostic issues (45.5%) and suboptimal follow-up (15.2%).
Conclusion
One in 40 children suffered adverse events related to ED care. A high proportion of events were preventable. Management and diagnostic issues warrant further study.
Objective
In this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway.
Materials and methods
We conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS).
Results
Emergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; p<0.01) and performed experimental tasks faster with the PE-Dx CDS (on average 96 s per scenario with PE-Dx; 117 s with web-based CDS; p<0.001). They also reported lower workload (p<0.001) and higher satisfaction (p<0.001) with PE-Dx.
Conclusions
This simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety.
Objective
This study reviews theoretical models of organizational safety culture to uncover key factors in safety culture development.
Background
Research supports the important role of safety culture in organizations, but theoretical progress has been stunted by a disjointed literature base. It is currently unclear how different elements of an organizational system function to influence safety culture, limiting the practical utility of important research findings.
Method
We reviewed existing models of safety culture and categorized model dimensions by the proposed function they serve in safety culture development. We advance a framework grounded in theory on organizational culture, social identity, and social learning to facilitate convergence toward a unified approach to studying and supporting safety culture.
Results
Safety culture is a relatively stable social construct, gradually shaped over time by multilevel influences. We identify seven enabling factors that create conditions allowing employees to adopt safety culture values, assumptions, and norms; and four behaviors used to enact them. The consequences of these enacting behaviors provide feedback that may reinforce or revise held values, assumptions, and norms.
Conclusion
This framework synthesizes information across fragmented conceptualizations to clearly depict the dynamic nature of safety culture and specific drivers of its development. We suggest that safety culture development may depend on employee learning from behavioral outcomes, conducive enabling factors, and consistency over time.
Application
This framework guides efforts to understand and develop safety culture in practice and lends researchers a foundation for advancing theory on the complex, dynamic processes involved in safety culture development.
Introduction
Emergency Medicine (EM) is a unique clinical learning environment. The American College of Graduate Medical Education Clinical Learning Environment Review Pathways to Excellence calls for “hands-on training” of disclosure of medical error (DME) during residency. Training and practicing key elements of DME using standardized patients (SP) may enhance preparedness among EM residents in performing this crucial skill in a clinical setting.
Methods
This training was developed to improve resident preparedness in DME in the clinical setting. Objectives included the following: the residents will be able to define a medical error; discuss ethical and professional standards of DME; recognize common barriers to DME; describe key elements in effective DME to patients and families; and apply key elements during a SP encounter. The four-hour course included didactic and experiential learning methods, and was created collaboratively by core EM faculty and subject matter experts in conflict resolution and healthcare simulation. Educational media included lecture, video exemplars of DME communication with discussion, small group case-study discussion, and SP encounters. We administered a survey assessing for preparedness in DME pre-and post-training. A critical action checklist was administered to assess individual performance of key elements of DME during the evaluated SP case. A total of 15 postgraduate-year 1 and 2 EM residents completed the training.
Results
After the course, residents reported increased comfort with and preparedness in performing several key elements in DME. They were able to demonstrate these elements in a simulated setting using SP. Residents valued the training, rating the didactic, SP sessions, and overall educational experience very high.
Conclusion
Experiential learning using SP is effective in improving resident knowledge of and preparedness in performing medical error disclosure. This educational module can be adapted to other clinical learning environments through creation of specialty-specific scenarios.
Simulation is a powerful tool for education and quality improvement in emergency medicine, and simulation-based curricula demonstrate improved health care outcomes in select domains. Simulation-the use of trained actors, anatomic models, computer-based task trainers and mannequins, and virtual reality environments to create realistic care scenarios in a purely educational setting-can provide crucial training in the procedural, communications, and teamwork skills required to provide high-quality medical care. This chapter identifies the performance gaps in clinical training, the learning theories, and evaluation methods that support the efficacy of simulation-based education, and discusses how simulation training is currently being used to address the identified performance gaps in emergency medicine.
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.
The registration of surgical complications is an important quality indicator of hospital medical care. Previous research has suggested that surgeons only record certain complications after discharge. The extent and impact of this potential under-recording of post-discharge complications is unknown. Therefore, we aimed to determine the frequency, type, and grade of post-discharge complications as reported by patients and their surgeons.
A prospective cohort study was performed in the Department of Surgery of a University Medical Center. From December 2008 until August 2009, all adult surgical patients were interviewed by phone or questionnaire 1 month after their discharge to inquire about any new complications after discharge. These complications were compared with the surgeon-reported post-discharge complications and letters from the outpatient clinic as documented in the patients' medical files.
A total of 976 patients were included. Patients reported more complications (659) than did surgeons (465), especially psychological disturbances (4.2 vs. 0 %). A medical consult was needed in 527 (80 %) of the patient-reported complications. Of all patient-reported complications, 291 (44 %) resulted in a visit to the outpatient clinic, 144 (22 %) in a consultation with a general practitioner, and 92 (14 %) led to referral to a hospital; 743 (76 %) were treated non-operatively.
Surgeons are unaware of many of the complications their patients experience after discharge. These post-discharge complications are important to patients and are therefore relevant to be aware of and to act upon whenever necessary.
This paper describes the design of a patient safety program for the emergency department of a highly complex tertiary care university hospital. The program comprises a broad set of preventive measures for reducing the risk of identified adverse events. An expert working group within the emergency department undertook the following steps to create the program: 1) brainstorming to identify the potential adverse events that occur in the emergency department as well as the errors and contributing factors responsible for them, 2) ranking of the adverse events according to a risk priority index by means of failure mode and effect analysis, 3) listing recommendations for risk reduction, and 4) mapping risks onto the overall emergency care process. The working group identified 43 adverse events, 65 types of error, 86 causes, and 207 ameliorating actions. Each adverse event generated between 1 and 21 ameliorating actions. Problems with the clinical care process accounted for 46.51% of the total, medication incidents for 13.95%, the diagnostic process for 6.97%, procedures for 6.97%, and infections for 2.32%. Other types of incidents accounted for 23.26% of the total. Our experience underlines the importance of creating a patient safety culture in an emergency department. Such a culture can be created by first analyzing and ranking adverse events according to level of risk and then planning ameliorating actions that reduce risk.
Patient safety concerns have focused attention on organisational and safety cultures, in turn directing attention to the measurement of organisational and safety climates.
First, to compare levels of agreement between survey- and observation-based measures of organisational and safety climates/cultures and to compare both measures with criterion-based audits of the quality of care, using evidence-based markers drawn from national care standards relating to six common clinical conditions. (This required development of an observation-based instrument.) Second, to examine whether observation-based evaluations could replace or augment survey measurements to mitigate concerns about declining response rates and increasing social desirability bias. Third, to examine mediating factors in safety and organisational climate scores.
The study had three strands: (A) a postal questionnaire survey to elicit staff perceptions of organisational and safety climates, using six prevalidated scales; (B) semistructured non-participant observation of clinical teams; and (C) a retrospective criterion-based audit carried out by non-clinical auditors to minimise hindsight bias. Standardised summary scores were created for each strand, and pairs of measurements were compared (strand A with strand B, strand A with strand C, and strand B with strand C) using Bland-Altman plots to evaluate agreement. Correlations were also examined. Multilevel modelling of Strand A scores explored mediating factors.
Eight emergency departments and eight maternity units in England, UK.
None.
Examination of feasibility, correlation and agreement.
Strand A: the overall response rate was 27.6%, whereas site-specific rates ranged from 9% to 47%. We identified more mediating factors than previous studies; variable response rates had little effect on the results. Organisational and safety climate scores were strongly correlated (r = 0.845) and exhibited good agreement [standard deviation (SD) differences 0.449; 14 (88%) within ± 0.5; one large difference]. Two commonly used scales had high levels of positive responses, suggesting positive climates or social desirability bias. Strand B: scoring on a four-point scale was feasible. Observational evaluation of teamwork culture was good but too limited for evaluating organisational culture. Strand C: a total of 359-399 cases were audited per condition. The results varied widely between different markers for the same condition, so selection matters. Each site performed well on some markers but not others, with few consistent patterns. Some national guidelines were contested. Comparisons: the comparison of safety climate (survey) and teamwork culture (observation) revealed a moderately low correlation (r = 0.316) and good agreement [SD differences 1.082; 7 (44%) within ±0.5; one large difference]. The comparison of safety climate (survey) and performance (audit) revealed lower correlation (r = 0.150, i.e. relationship not linear) but reasonably good agreement [SD differences 0.992; 9 (56%) within ± 0.5; two large differences]. Comparisons between performance (audit) and both organisational climate (survey) and teamwork culture (observation) showed negligible correlations (< 0.1) but moderately good agreement [SD differences 1.058 and 1.241; 6 (38%) and 7 (44%) within ± 0.5; each with two large differences (at different sites)]. Field notes illuminated large differences.
Climate scores from staff surveys are not unduly affected by survey response rates, but increasing use risks social desirability bias. Safety climate provides a partial indicator of performance, but qualitative data are needed to understand discrepant results. Safety climate (surveys) and, to a lesser degree, teamwork culture (observations) are better indicators of performance than organisational climate (surveys) or attempts to evaluate organisational culture from time-limited observations. Scoring unobtrusive, time-limited observations to evaluate teamwork culture is feasible, but the instrument developed for this study needs further testing. A refined observation-based measure would be useful to augment or replace surveys.
The National Institute for Health Research Health Technology Assessment programme.
The application of main methodologies for clinical decision-making by residents in emergency medical practice was assessed, and issues in this area were investigated. The treatments provided to 2 611 critical patients by the Emergency Department of Peking Union Medical College Hospital were analyzed by independent investigators who evaluated the main clinical decision-making processes applied by the hospital residents. The application of decision-making strategies by PG1 and PG3 groups, which means the residents in first year and the third year, were compared. The patients were treated according to pattern recognition (43.0%), hypothetico-deductive reasoning (23.4%), event-driven models (19.3%), and rule-using algorithms (5.9%). A significant difference was found between PG1 and PG3 groups (χ(2)= 498.01, P < 0.001). Pattern recognition and hypothetic-deductive methods were the most common techniques applied by emergency physicians in evaluating critically ill patients. The decision-making processes applied by junior and senior residents were significantly different, although neither group adequately applied rule-using algorithms. Inclusion of clinical decision-making in medical curricula is needed to improve decision-making in critical care.
This report presents the most current (2006) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics.
Data are from the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates.
In 2006 there were 119.2 million visits to hospital EDs, or 40.5 visits per 100 persons, continuing a long-term rise in both indices. The rate of visits per 100 persons was 36.1 for white persons, 79.9 for black persons, and 35.3 for Hispanic persons. ED occupancy (the count of patients who had arrived, but not yet discharged, transferred, or admitted) varied from 19,000 patients at 6 a.m. to 58,000 at 7 p.m. on an average day nationally. Though overall ED visits increased, the number of visits considered emergent or urgent (15.9 million) did not change significantly from 2005, nor did the number of patients arriving by ambulance (18.4 million). At 3.6 percent of visits, the patient had been seen in the same ED within the previous 72 hours. Median time to see a clinician was 31 minutes. Of all ED visits, 35.6 percent were for an injury. Patients had computerized tomography or magnetic resonance imaging at 12.1 percent of visits, blood drawn at 38.8 percent, an intravenous line started at 24.0 percent, an x ray performed at 34.9 percent, and an electrocardiogram done at 17.1 percent. Patients were admitted to the hospital at 12.8 percent of ED visits in 2006. The ED was the portal of admission for 50.2 percent of all nonobstetric admissions in the United States in 2006, an increase from 36.0 percent in 1996. Patients were admitted to an intensive care unit at 1.9 percent of visits.
Normal Accidents analyzes the social side of technological risk. Charles Perrow argues that the conventional engineering approach to ensuring safety--building in more warnings and safeguards--fails because systems complexity makes failures inevitable. He asserts that typical precautions, by adding to complexity, may help create new categories of accidents. (At Chernobyl, tests of a new safety system helped produce the meltdown and subsequent fire.) By recognizing two dimensions of risk--complex versus linear interactions, and tight versus loose coupling--this book provides a powerful framework for analyzing risks and the organizations that insist we run them. The first edition fulfilled one reviewer's prediction that it "may mark the beginning of accident research." In the new afterword to this edition Perrow reviews the extensive work on the major accidents of the last fifteen years, including Bhopal, Chernobyl, and the Challenger disaster. The new postscript probes what the author considers to be the "quintessential 'Normal Accident'" of our time: the Y2K computer problem.
Clinical decision making (CDM) describes a form of qualitative inquiry that examines the thought processes involved in making medical decisions. A significant body of literature exists on the orderly “hypothetico-deductive” model of clinical decision making. However, very little has been written on how CDM differs in the acute setting. This paper reviews the common methods of CDM and their relevance to emergency medicine (EM). The concept of diagnostic uncertainty and the utility of the diagnosis of unknown etiology in the disposition phase of the emergency patient visit are discussed. Finally, a unique EM perspective on clinical decision-making errors is presented.
Imagine two assembly lines, monitored by two foremen. Foreman 1 walks the line, watching carefully. "I can see you all," he warns. "I have the means to measure your work, and I will do so. I will find those among you who are unprepared or unwilling to do your jobs, and when I do there will be consequences. There are many workers available for these jobs, and you can be replaced." Foreman 2 walks a different line, and he too watches. "I am here to help you if I can," he says. "We are in this together for the long . . .
The objectives of this study were 1) to determine the frequency with which adverse drug events result in an incident report (IR) in hospitalized patients; and 2) to determine if there were differences between quality assurance administrators, nurse leaders in quality assurance, and staff nurses as to whether an incident report should or would be filed for each adverse drug event.
All patients admitted to five patient care units (one medical intensive care unit, two surgical intensive care units, and two medical general care units) in one academic tertiary care hospital were studied between February and July 1993. The main outcome measures used were adverse drug events (ADEs) and IRs. Consensus voting was used by senior hospital administrators, nursing leaders, and staff nurses to determine whether an adverse drug event should have been reported and would have been reported.
Of 54 adverse drug events identified by the study, only 3 patients (6%) had a corresponding incident report submitted to the hospital's quality assurance program or called into the pharmacy hotline. One additional ADE was identified by an IR, but not by the ADE study. Of the 55 ADEs, 15 were preventable, and 26 were serious or life-threatening, yet only 2 of the 26 led to an incident report. The three voting groups agreed that most ADEs justified an IR, but judged that in actual practice, an IR would infrequently have been filed.
Voluntary reporting identified only a small fraction of ADEs. Using IRs for quality assurance/quality improvement will lead to significant bias when assessing quality of care.
Demonstration of quality health care includes documentation of outcomes of care. Surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the health care team to assist in improving those outcomes. Surveillance is an essential component of effective clinical programs designed to reduce the frequency of adverse events such as infection or injury. Although there is no single or "right" method of surveillance design or implementation, sound epidemiologic principles must form the foundation of effective systems and must be understood by key participants in the surveillance program and supported by senior management. Teamwork and collaboration across the health care spectrum are important for the development of surveillance plans. Each health care organization must tailor its surveillance systems to maximize resources by focusing on population characteristics, outcome priorities, and organizational objectives. To ensure quality of surveillance, the following elements must be incorporated: A written plan should serve as the foundation of any surveillance program. The plan should outline important objectives and elements of the surveillance process so that resources can be targeted appropriately. Thoroughness or intensity of surveillance for an area of interest must be maintained at the same level over time. Fluctuations of a surveillance rate have no meaning unless the same level of data collection is maintained. External rate comparisons are meaningless unless the systems used have comparable intensity. All the elements of surveillance should be used with consistency over time. This includes application of surveillance definitions and rate calculation methods. Personnel resources need to be appropriate for the type of surveillance being performed. This includes trained professionals who understand epidemiology and who have access to continuing professional education opportunities. Other resources essential to surveillance include computer support, information and technology services, clerical services, and administrative understanding and support to maintain a quality program. As a means of quality control and to ensure accuracy, the data and process of surveillance should undergo periodic evaluation and validation. This document is intended to assist professionals who plan and conduct surveillance programs as well as those who assure that there is appropriate organizational support to accomplish appropriate surveillance. While design of surveillance systems must be unique for each organization, incorporation of these seven core Recommended Practices for Surveillance provides a scientific framework to approach surveillance programs.
To develop a graded classification system for risks in emergency medicine. To test the inter-user reliability of this classification system.
Prospective collection of data involving emergency department (ED) critical incidents. Derivation of classification system using the collected critical incidents. Comparison of results of classification of a sample of the critical incidents between different users of the system.
EDs in two teaching hospitals and two district general hospitals (DGHs) in the north west of England.
Observational study.
Classification system itself. Results of classification of same critical incidents by different users.
816 critical incidents were identified and used to derive a typology. This typology was found to have inter-user reliability score of 86% (95% confidence intervals 76.4% to 95.6%).
The typology that has been derived is a reliable tool for the classification of risks in emergency medicine.
Standardizing a Patient Safety Taxonomy
- Anon
Anon. Standardizing a Patient Safety Taxonomy. Washington, DC: National Quality Forum, 2006.