Elsevier

Annals of Emergency Medicine

Volume 42, Issue 3, September 2003, Pages 324-333
Annals of Emergency Medicine

The Practice of Emergency Medicine
Errors in a busy emergency department

https://doi.org/10.1016/S0196-0644(03)00398-6Get rights and content

Abstract

Study objective

We describe errors occurring in a busy ED.

Methods

This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100,000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets.

Results

One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P<.0001) and more likely to have higher visit level intensity (P<.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome.

Conclusion

Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.

Introduction

Adverse events caused by medical error are estimated to cause between 44,000 and 98,000 deaths every year in the United States1 and are considered a major problem in patient safety. The emergency department (ED) has been identified as a hospital location where adverse events are highly likely to be attributable to errors.1, 2, 3, 4 Estimates of the proportion of ED adverse events deemed to be preventable range from 53%2 to 82%3 compared with overall estimates of 27%2 to 51%3 for hospital-based adverse events. A number of factors are likely to predispose to higher error rates in emergency care.5 Emergency medicine is characterized by the simultaneous care of multiple patients with a wide variety of conditions, a substantial proportion of whom are acutely ill. Emergency care providers often have to work in conditions involving disrupted sleep cycles, multiple interruptions,6 acute time constraints, and crowding and must institute major medical interventions for patients according to limited historical and diagnostic information.

The study of medical errors and adverse events has increasingly considered systems of health care delivery rather than staff who commit errors because of poor system design. This approach to error reduction has been used successfully in aviation and other industries for many years.1 Clinical staff are encouraged to be active participants in the detection and investigation of errors rather than being the subjects of scrutiny and scapegoating. No-fault reporting of errors and adverse events has been used as a part of this process to allow staff to contribute information about the delivery of medical care while being protected from punitive measures arising from subsequent investigation.

Reporting errors and adverse events has most commonly been an activity initiated by medical or nursing staff using an incident reporting system. This process can produce valuable information about adverse events7 but has been shown to detect only a small fraction of errors and adverse events demonstrable by other means.8, 9 Some reasons cited for the relatively low numbers of incidents reported include varying perceptions about what constitutes a reportable event and workload pressures concerning the time and effort taken to report.9, 10 Active solicitation of error reports, in which staff are regularly questioned about the occurrence of errors and adverse events, attempts to minimize these disincentives to reporting and thereby increase the number of reports obtained. We used active solicitation of error reports, with a no-fault outlook, to maximize identification of errors occurring throughout a 1-week period in a busy ED.

Section snippets

Methods

We conducted a prospective, observational study of errors in emergency care as identified by ED staff by means of active solicitation of error reports. The study protocol was approved by the institutional review board by expedited review, with a waiver of the requirement of written informed consent. Information obtained for this study is protected from legal discovery under Commonwealth of Massachusetts peer review legislation.

The study was performed throughout a 1-week period in the ED at a

Results

During the study week, 1,935 patients were registered to be treated in the ED. Four hundred error reports were completed during the 7-day study period. Eleven errors were described in multiple reports, and 9 reports described multiple errors. Fifty reports were excluded from analysis because of not meeting inclusion criteria, which left a total of 346 nonduplicative errors, described in 350 error reports, giving 18 errors for every 100 registered patients (95% CI 15.9 to 20.0). Seven of the 346

Discussion

Eighteen errors in emergency care were identified for every 100 patients treated in a large tertiary care hospital ED throughout a 7-day period. Two percent of these errors resulted in adverse events. Extrapolation of these rates to the more than 100 million ED visits annually14 implies that more than 18 million errors and 360,000 adverse events occur each year in the United States.

The categorization scheme used in this study differs from previously published taxonomies of errors. This choice

Acknowledgments

Author contributions: All authors were involved with study concept and design, analysis and interpretation of the data, and critical revision of the manuscript. JF and FSJB were responsible for acquisition of data. JF drafted the manuscript. PP provided statistical expertise. PP, HAS, GR, SG, EB, and PLH provided supervision and administrative support. EB and PLH provided funding. PLH takes responsibility for the paper as a whole.

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Cited by (0)

Presented at the Society of Academic Emergency Medicine annual meeting, St. Louis, MO, May 2002.

Supported in part by the Department of Emergency Medicine Research and Education Fund, Baystate Medical Center, Springfield, MA.

Reprints not available from the authors.

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