Abstract
BackgroundSeveral studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs) are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.MethodsStudy at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA) by an experienced researcher.Results522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%), followed by organisational (25%) and technical causes (11%). Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital.ConclusionEvent reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.
Highlights
Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals
Several studies in various countries have shown that a substantial number of patients suffer from adverse events in hospitals. [1,2,3,4,5,6,7,8,9] These studies have reported adverse event incidence rates ranging from 3% to 17% of all hospital admissions, with 25% to 50% of the adverse events considered preventable
General findings and interpretation We gathered and analysed a large number of unintended events (522) using a root cause analysis tool based on the sound theoretical frameworks of Reason and Rasmussen, which is accepted by the WHO and which has a good reliability.[27]
Summary
Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety This can only be achieved if interventions tackle the dominant underlying causes. The ED is a challenging hospital setting because high patient throughput, heavy dependence on services outside the ED (laboratory, radiology, consulting services etc.) and the diversity of clinical conditions presented.[11] Emergency care providers often have to work under conditions involving disrupted sleep cycles, multiple interruptions and acute time constraints, and they have to institute major medical interventions for patients with limited historical and diagnostic information.[12] Since large numbers of patients visit the ED, the incidence rate of adverse events in the ED and the large proportion that is preventable are alarming and require interventions. An increase in patient safety can only be achieved if these interventions tackle the right underlying causes
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