Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process
Authors
Jepson, Zach K.Darling, Chad E.
Kotkowski, Kevin A
Bird, Steven B.
Arce, Michael W.
Volturo, Gregory A.
Reznek, Martin A
UMass Chan Affiliations
Department of Emergency MedicineDocument Type
Journal ArticlePublication Date
2014-08-08
Metadata
Show full item recordAbstract
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.Source
BMC Emerg Med. 2014 Aug 8;14:20. doi: 10.1186/1471-227X-14-20. Link to article on publisher's siteDOI
10.1186/1471-227X-14-20Permanent Link to this Item
http://hdl.handle.net/20.500.14038/39632PubMed ID
25106803Related Resources
Link to Article in PubMedDistribution License
http://creativecommons.org/licenses/by/4.0/ae974a485f413a2113503eed53cd6c53
10.1186/1471-227X-14-20
Scopus Count
Except where otherwise noted, this item's license is described as http://creativecommons.org/licenses/by/4.0/