A patient was assigned to an EP who was not on duty in the ED at the time. As a result, a critical test result was not reported. This is a de-identified example of an actual event reported by EDs to Pennsylvania’s Patient Safety Authority involving the time period between diagnostic testing and disposition decision. The authority’s March 2015 advisory analyzed 2,495 events that occurred during this phase of the ED visit.

“The data showed us that this phase had multiple components to it,” says senior patient safety/quality analyst Mary C. Magee, RN, MSN, CPHQ. The authority broke down the phase into these components:

• Treatments and procedures: Reports involved errors in ordering and executing, complications, and adverse reactions. In one case, a weight-based medication was administered based on a technician’s report of the patient’s weight in kilograms instead of pounds; the patient was emergently intubated and a tracheal tear surgically repaired.
• Diagnostic testing: Reports included errors in ordering, executing, and resulting, such as misidentification of patients, delays, contrast infiltrations, and laboratory or radiology test problems. In one case, a patient’s EKG was misplaced, with abnormal findings discovered two days later when the final reading was done electronically.
• Monitoring and reassessments: Reports included unwitnessed falls with injury, leaving against medical advice or without treatment being completed, clinical status changes, equipment malfunctions, unplanned extubations, self-inflicted injuries, and accidental injuries during care. In one case, a patient who was found unresponsive in the bathroom required intubation and admission.
• Consults: One ED reported a delay in getting a patient in cardiac arrest to the cardiac catheterization lab caused by confusion over which cardiologist was on call.
• The diagnostic decision process: One case involved a patient discharged from an ED with a diagnosis of fractured ribs; radiology later read the patient’s X-ray as positive for pneumothorax.

After identifying trends based on the events that were reported to the database, “we then looked to the literature to see if there were strategies that could help ED staff to prevent or at least minimize error,” Magee says.

For example, for diagnostic testing, the report recommends simplification and standardization of specimen collection and labelling procedures and verifying patient orders before they’re entered electronically. (The complete report is available at http://bit.ly/1RYeAlN.)

The de-identified narratives in the report, which are based on actual incidents, “probably ring true to every ED,” says medical director Ellen S. Deutsch, MD, MS, FACS, FAAP. “The suggestions of what steps they might take are evidence-based and may provide new ideas for some processes they can try or test out. For other EDs, it can confirm what they already think is effective.”

Magee says that EDs can benefit by comparing their own events to the advisory’s data. Opportunities to improve “may be identical to what was reported in the database, or they may differ,” she says. “From there, EDs can determine whether it makes sense to implement the recommended strategies in their setting, and what way to implement them,” she adds.

Deutsch recommends including “non-events” in the ED’s analysis, such as when a hazard was identified but did not progress to the point of impacting a patient, and when an intervention by a care provider prevented a patient from being harmed.

“Using some type of simulation can identify some opportunities for improvement before you get to the point where a near miss or event occurs,” she suggests.

EDs can see the potential for something not going according to plan, and adjust the process accordingly. “Many places use simulation to improve teamwork and communication,” Deutsch says. “It is less common to use simulation to examine the environment in which care is provided.”

REFERENCE

1. Pennsylvania Patient Safety Authority. Patient flow in the ED: Phase II — Diagnostic evaluation through disposition decision. Pa Patient Saf Advis 2015;12:7-18.

SOURCES

• Ellen S. Deutsch, MD, MS, FACS, FAAP, Medical Director, Pennsylvania Patient Safety Authority, Plymouth Meeting. Phone: (610) 825-6000 ext. 5387. E-mail: edeutsch@ecri.org.
• Mary C. Magee, RN, MSN, CPHQ, CPPS, Senior Patient Safety/Quality Analyst, Pennsylvania Patient Safety Authority, Plymouth Meeting. Phone: (610) 825-6000, ext. 5487. Fax (610) 567-1114. E-mail: mmagee@ecri.org.