Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Freund, Yonathan; Goulet, Hélène; Bokobza, J.; Ghanem, A.; Carreira, Serge; Madec, Delphine; Leroux, Gaëlle; Ray, Patrick; Boddaert, Jacques; Riou, Bruno; Hausfater, Pierre

doi:10.1016/j.jemermed.2012.11.061

Cited by 36 publications

(44 citation statements)

References 18 publications

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“…Since the incidents were reported by physicians who are directly involved in patient care, it is possible that a bias towards reporting less significant errors with minimal patient impact may have resulted in patient harm being under-reported. However, almost one-fifth of errors were still found to lead to severe harm, which is comparable with studies that did not involve reporting 3 8 10. Recall bias could also have impacted the level of detail reported if the reporter did not report the incident immediately after the event.…”

Section: Discussionsupporting

confidence: 57%

“…The authors reported on ED diagnostic errors, but statistics for diagnostic and treatment errors were combined. While other studies have assessed ED errors through malpractice claims,10 ED staff interviews,9 downstream reports by hospital ward physicians3 and mortality and morbidity reports,8 none of these studies focused on diagnostic errors. Our study is unique in that we specifically focused our analysis on diagnostic-related incidents voluntarily reported by ED physicians that occurred in the ED.…”

Section: Discussionmentioning

confidence: 99%

“…Diagnostic error is likely to be one of the most common types of errors in the ED setting 3 4 8–10. A study of closed malpractice claims found that 65% of the claims involved missed ED diagnoses, of which, 48% caused serious harm, and 39% resulted in death 10.…”

Section: Introductionmentioning

confidence: 99%

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Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

et al. 2015

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Objectives Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Methods Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospitalaffiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Results Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/ conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Conclusions Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED.

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Section: Discussionsupporting

confidence: 57%

Section: Discussionmentioning

confidence: 99%

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Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

et al. 2015

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“…Previously the literature related to ED overcrowding has identified delays in diagnosis, delays in treatment and poor patient outcomes as the result of exceeding ED capacity. 4,[29][30][31][32] Specifically this study identified that medication safety is compromised when the ED cubicles are over 50% occupied which could indicate that the ED does not have to be at the point of 'exceeding capacity' to impact patient safety. In fact systems become stretched when the high acuity areas of the ED, such as the resuscitation cubicles become over 50% occupied and increased medication omissions occur.…”

Section: Discussionmentioning

confidence: 89%

Medication errors in ED: Do patient characteristics and the environment influence the nature and frequency of medication errors?

Scott

Considine

Botti

2014

Australasian Emergency Nursing Journal

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“…Medical errors affected 85,000 people in the UK annually, leading patients to stay two more days in health facilities (17,18). In France, 10,000 deaths are associated with medical errors annually (19).…”

Section: Introductionmentioning

confidence: 99%

SHERPA Technique as an Approach to Healthcare Error Management and Patient Safety Improvement: A Case Study among Nurses

et al. 2016

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Background: Overcoming the challenge of human error occurrence in the healthcare section and patient safety improvement is impossible without understanding the nature of human error and without considering the fundamentals of human factors and ergonomics in designing and implementing sociotechnical systems. Therefore, the first step is to identify medical errors and their causes, using standard methods. Objectives: The aim of this study was to identify and evaluate human errors among nurses in the women's infectious diseases ward in an educational hospital in the city of Qom in 2015. Methods: This cross-sectional study was performed to identify the medical errors among sixteen female nurses working in the women's infectious diseases ward, using SHERPA. Hierarchical task analysis (HTA) was performed; errors were identified by checklist and risk assessment was then carried out. Results: One hundred fifty-nine errors were identified and evaluated in 89 tasks. Most of the detected errors were of the action type (74.21%) and the least errors were of the selection type (0.63%). The least number of the errors' risk level was placed in the undesirable, and the highest was in the unacceptable level. Conclusions: Since the majority of the errors were of the action type, proper measures should be taken to prioritize them in disease control. In addition, designing a treatment process based on human factors and ergonomic principles is highly recommended to enhance the quality of services, improve patient safety and reduce errors. With respect to task analysis, the SHERPA is a good technique to evaluate and monitor medical errors.

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Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Cited by 36 publications

References 18 publications

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

Medication errors in ED: Do patient characteristics and the environment influence the nature and frequency of medication errors?

SHERPA Technique as an Approach to Healthcare Error Management and Patient Safety Improvement: A Case Study among Nurses

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