ObjectivesThis study describes the proportion of emergency department (ED) returns within 7 days due to adverse events, defined as adverse outcomes related to healthcare received.DesignProspective cohort study.SettingWe used an electronically triggered adverse event surveillance system at a tertiary care ED from May to June 2010 to examine ED returns within 7 days of index visit.ParticipantsOne of three trained nurses determined whether the visit was related to index emergency care. For such records, one of three trained emergency physicians conducted adverse event determinations.Main outcome measureWe determined adverse event type and severity and analysed the data with descriptive statistics, χ2 tests and logistic regression.ResultsOf 13 495 index ED visits, 923 (6.8%) were followed by ED returns within 7 days. The median age of all patients was 47 years and 52.8% were women. After nursing review, 211 cases required physician review. Of these, 53 visits were adverse events (positive predictive value (PPV)=5.7%, 95% CI 4.4% to 7.4%) and 30 (56.6%) were preventable. Common adverse event types involved management, diagnostic or medication issues. We observed one potentially preventable death and 58.5% of adverse events resulting in transient disability. The PPV of a modified trigger with a cut-off of return within 72 h, resulting in admission was 11.9% (95% CI 6.8% to 18.9%).ConclusionsOur electronic trigger efficiently identified adverse events among 12% of patients with ED returns within 72 h, requiring hospital admission. Given the high degree of preventability of the identified adverse events, this trigger also holds promise as a performance measurement tool.

ObjectivesEmergency department (ED) resuscitation is a complex, high‐stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm. MethodsAs part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis. ResultsDuring the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be “actionable” at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases.ConclusionsEffective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

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Introduction / Innovation Concept: During Emergency Department (ED) resuscitation of critically ill patients, effective teamwork and communication among various healthcare professionals is essential to ensure favorable patient outcomes and to minimize threats to patient safety. However, numerous individual and system factors create barriers to effective team functioning. Simulation center- based training has been used to improve Crisis Resource Management skills among physician and nursing trainees, but in-situ simulation is a relatively new concept in adult Emergency Medicine in North America. Methods: To enhance patient care and team effectiveness, an ED nursing and physician group was created to develop and implement a novel interprofessional in-situ simulation program in two Canadian, academic tertiary-care emergency departments. Departmental approval and financial support was obtained and sessions commenced in January 2015. Curriculum, Tool, or Material: Monthly high-fidelity simulation sessions are held in the ED resuscitation rooms at both campuses of our hospital. Each session is facilitated and debriefed by simulation-trained Emergency Medicine faculty and senior residents, a nurse educator and a research assistant. Technical support is provided by our simulation center staff. Participants are recruited from the physicians, residents, nurses, respiratory therapists and other support staff working in the ED. To minimize the impact on patient care, two additional nurses are scheduled to cover nursing assignments on “sim days”. Simulations are limited to fifteen minutes, followed by a twenty minute debriefing. Conclusion: We have successfully developed and implemented an interprofessional in-situ simulation program in our ED. Participant feedback has been overwhelmingly positive. Lack of financial support, reluctance of staff to participate, and overwhelmed resources are some of the challenges to running a program like this in a busy ED environment. However, there are clear benefits: empowering team members, culture change, identification of latent safety threats, and a perception of improved teamwork and communication.

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