Pre-IVRS (n=487) | Post-IVRS (n=481) | |
Flagged outcomes | 155 (31.8%) | 160 (33.3%) |
Number of patients with adverse events | 10 (2.1%) | 16 (3.3%) |
Adverse events (proportion relative to number of flagged outcomes) | 10 (6.5%) | 27 (16.9%) |
Adverse event type* | ||
Diagnostic issue | 6 | 13 |
Unsafe disposition decision | 5 | 11 |
ED management issue | 2 | 3 |
Suboptimal follow-up | 1 | 2 |
Procedural complication | 0 | 3 |
Adverse drug effect | 0 | 2 |
Nosocomial infection | 0 | 1 |
Severity | ||
Deaths | 0 | 1 |
Admissions | 6 | 7 |
Return to ED and discharged | 3 | 10 |
Number of patients with preventable adverse events | 9 (1.8%) | 13 (2.7%) |
Preventable adverse events | 9 (1.8%) | 24 (4.9%) |
System issue identified | ||
Inadequate monitoring of patient treatment in ED or postdischarge | 6 | 7 |
Premature ED discharge | 2 | 5 |
Communication issue between consultant and emergency physician | 2 | 0 |
Delayed follow-up | 1 | 0 |
Healthcare worker hygiene issue | 0 | 2 |
Inadequate monitoring of patient illness in ED or postdischarge | 0 | 2 |
*Adverse events may have more than one type.
IVRS, interactive voice response system.