Patient Safety In Emergency Department Research Articles

Color-Coding and Human Factors Engineering to Improve Patient Safety Characteristics of Paper-Based Emergency Department Clinical Documentation

Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented. Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments. During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40). Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.

Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients – a national review

Despite an increase in research, there is still a lack of knowledge about patient safety in emergency departments (EDs) in many European countries. The aim of this study was therefore to describe the incidence and types of reported medical errors and complaints in ED care in Sweden. Data reported in 2009 were gathered from national authorities, including the National Board of Health and Welfare, the Medical Responsibility Board, the Patients Advisory Committees, and local incident-reporting systems. Data were analyzed by content analysis. Among 428 cases reported by care providers to the National Board of Health and Welfare, 64 (15.0%) were related to ED care. As several cases contained more than one medical error, 92 errors were identified, out of which 39 (42.4%) were related to diagnostic procedures. Among the 4628 cases of complaints reported by patients to the Medical Responsibility Board, 306 (6.6%) were related to ED care. In total, 437 complaints regarding perceived medical errors were identified (several cases contained more than one error), with 189 (43.2%) pertaining to diagnostic procedures. A total of 1341 complaints about ED care were made by patients to the Patients Advisory Committees (n=21), of which 655 (48.8%) were related to care and treatment. There were 7434 medical errors reported to local incident-reporting systems at the EDs (n=45). Of these, 1450 (19.5%) referred to care and treatment. Medical errors and complaints at Swedish EDs, as reported by both patients and care providers, were related mainly to diagnostic procedures and treatments.

Developing nonlinear queuing regressions to increase emergency department patient safety: Approximating reneging with balking

Administrators know when Emergency Department (ED) overcrowding is a problem in their hospital. Lead times to change ED capacity are long and require strategic tools. ED patients who Leave WithOut Treatment (LWOT) before seeing a physician are, in queuing nomenclature, ‘reneging’ from an overcrowded situation and are an important measure of ED patient safety. We propose to enable strategic decision making on future ED capacity on the basis of patient safety (rather than congestion measures). We hypothesize that the LWOT reneging percentage is captured by the balking probability ( p K ) relationship of an M/M/1/K queue. If true, this relationship is superior to the typical ad hoc regression relationships commonly found. Since it is based on a physical scientific mechanism, the sample size requirements and extrapolation power are improved. We derive the form of a binomial response nonlinear weighted regression model that best fits p K for predicting LWOT to long-term ED performance by means of Gauss–Newton linearization. Our results include asymptotic Wald confidence intervals on prediction, specific Pearson and Deviance model goodness-of-fit tests, and residual analysis that facilitate identification of outlying data points. None of these features exist for reneging (or balking) models previously presented in the literature.

La seguridad del paciente en urgencias y emergencias

Patient safety is an essential dimension of quality in Emergency Departments (EDs). The incidence of appearance of adverse events in these departments is estimated at between 1.6 and 14% according to different studies and methodologies. The strategies for achieving a safe clinical practice in EDs involve policies aimed at improving safety in the use of medication with special emphasis on the administration and on the reconciliation of the medication, as well as on the employment of high risk drugs; on preventing nosocomial infection due to emergency care, with special importance manual hygiene; on improving patient identification; on improving communication and information, especially during patient transfers; on the prevention of specific risks; and, above all, on creating a climate and culture of patient safety in EDs. Different proactive and reactive tools are available for evaluating patient safety in EDs. There is an outstanding need to publish the system of event notification to facilitate analysis of such events and the subsequent development of improvement actions in EDs.

Pediatric Patient Safety in Emergency Departments: Unit Characteristics and Staff Perceptions

The goals were (1) to describe emergency department (ED) characteristics thought to be related to patient safety within the Pediatric Emergency Care Applied Research Network, (2) to measure staff perceptions of the climate of safety in EDs, and (3) to measure associations between ED characteristics and a climate of safety. Twenty-one EDs were surveyed to assess physical structure, staffing patterns, overcrowding, medication administration, teamwork, and methods for promoting patient safety. A validated survey on the climate of safety was administered to all emergency department staff members. Safety climate scores were compared to evaluate associations with ED characteristics. A total of 1747 staff members (49%) responded to the survey on the climate of safety. A minority of EDs had organized safety activities such as safety committees (48%) or walk-rounds (38%), used computerized physician order entry (38%), had ED pharmacists (19%), or had formal physician/registered nurse teams (38%). The majority (67%) treated patients in hallways. Most (67%) varied staffing on the basis of seasonal patient volume. Of the 1747 ED staff members (49%) responding to the survey, there was a wide range (28%-82%) in the proportion reporting a positive safety climate. Physicians' ratings of the climate of safety were higher than nurses' ratings, and perceptions varied according to work experience. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee. Large variability existed among EDs in structures and processes thought to be associated with patient safety and in staff perception of the safety climate. Several ED characteristics were associated with a positive climate of safety.

Drug interactions in at-risk emergency department patients.

Many emergency department (ED) patients are at risk for drug interactions (DIs) because they are elders, and/or they have chronic illnesses requiring treatment with multiple medications. In the ED, medications may be added to complex treatment regimens without the benefit of screening for DIs. Emergency physicians may therefore cause DIs, or miss the opportunity to intervene against a pre-existing DI. Prior studies are contradictory regarding whether DIs are more likely to be due to medications administered or prescribed in the ED or medications prescribed elsewhere. Screening for DIs using computer software, such as that done by retail pharmacies, is now a standard of practice, and is done more frequently than when these other DI studies were reported during the previous decade. The authors monitored DIs among a focused, at-risk outpatient ED population, to test the hypothesis that ED-induced DIs have become the most common DIs in this population-at-risk. A retrospective convenience sample of 200 at-risk patients seen at a tertiary teaching hospital on selected dates of service was analyzed. Eligible patients were ED outpatients aged 60 years or more taking three or more medications, or any age taking five or more medications. Micromedex Drug-Reax software identified DIs. DIs had to represent "major" or "minor" severity, and have "excellent" or "good" literature documentation, to be scored as positive. Pre-existing versus ED-induced DIs were compared by chi-square. DIs were stratified by patient age and by number and type of medications taken. The 200 outpatients (125 female, 75 male) had a mean age (+/-SD) of 64.5 (+/-17.6) years and were taking an average of 7.2 medications. Seventy-nine pre-existing DIs were noted, occurring in 50 of the 200 patients studied. One hundred forty patients received a new medication during their ED visit. Seven new DIs (one in each of seven patients) occurred among these 140 patients. DIs were less frequently caused by medications added during the ED visit (chi(2) = 22.2, p < 0.001). Digoxin and warfarin were the sources of the greatest number of DIs. ED outpatients in the at-risk group frequently present with pre-existing DIs. Medications initiated in the ED are a less frequent cause of DI in this group. Medication screening during an ED visit could complement the role of outpatient pharmacies and potentially improve ED patient safety. DIs are most frequently due to digoxin and warfarin in these patients.

Drug Interactions in At‐risk Emergency Department Patients

Objectives: Many emergency department (ED) patients are at risk for drug interactions (DIs) because they are elders, and/or they have chronic illnesses requiring treatment with multiple medications. In the ED, medications may be added to complex treatment regimens without the benefit of screening for DIs. Emergency physicians may therefore cause DIs, or miss the opportunity to intervene against a pre‐existing DI. Prior studies are contradictory regarding whether DIs are more likely to be due to medications administered or prescribed in the ED or medications prescribed elsewhere. Screening for DIs using computer software, such as that done by retail pharmacies, is now a standard of practice, and is done more frequently than when these other DI studies were reported during the previous decade. The authors monitored DIs among a focused, at‐risk outpatient ED population, to test the hypothesis that ED‐induced DIs have become the most common DIs in this population‐at‐risk. Methods: A retrospective convenience sample of 200 at‐risk patients seen at a tertiary teaching hospital on selected dates of service was analyzed. Eligible patients were ED outpatients aged 60 years or more taking three or more medications, or any age taking five or more medications. Micromedex Drug‐Reax software identified DIs. DIs had to represent “major” or “minor” severity, and have “excellent” or “good” literature documentation, to be scored as positive. Pre‐existing versus ED‐induced DIs were compared by chi‐square. DIs were stratified by patient age and by number and type of medications taken. Results: The 200 outpatients (125 female, 75 male) had a mean age (±SD) of 64.5 (±17.6) years and were taking an average of 7.2 medications. Seventy‐nine pre‐existing DIs were noted, occurring in 50 of the 200 patients studied. One hundred forty patients received a new medication during their ED visit. Seven new DIs (one in each of seven patients) occurred among these 140 patients. DIs were less frequently caused by medications added during the ED visit (χ2= 22.2, p &lt; 0.001). Digoxin and warfarin were the sources of the greatest number of DIs. Conclusions: ED outpatients in the at‐risk group frequently present with pre‐existing DIs. Medications initiated in the ED are a less frequent cause of DI in this group. Medication screening during an ED visit could complement the role of outpatient pharmacies and potentially improve ED patient safety. DIs are most frequently due to digoxin and warfarin in these patients.