Fidela Blank

Errors in a busy emergency department.

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 100000 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.

Emergency Department Medication Lists Are Not Accurate

BACKGROUND Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list. OBJECTIVE To evaluate the accuracy of the ED home medication list. METHODS Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined. RESULTS There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46-66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70-87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78-93%). CONCLUSION Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.

Bar-code verification: reducing but not eliminating medication errors.

Using observation, eye tracking, and clinical simulation with embedded errors, we studied the impact of bar-code verification on error identification and recovery during medication administration. Data supported that bar-code verification may reduce but does not eliminate patient identification (ID) and medication errors during clinical simulation of medication administration.

Emergency department patients who stay more than 6 hours contribute to crowding

BACKGROUND Admitted and discharged patients with prolonged emergency department (ED) stays may contribute to crowding by utilizing beds and staff time that would otherwise be used for new patients. OBJECTIVES To describe patients who stay > 6 h in the ED and determine their association with measures of crowding. METHODS This was a retrospective, observational study carried out over 1 year at a single, urban, academic ED. RESULTS Of the 96,562 patients seen, 16,017 (17%) stayed > 6 h (51% admitted). When there was at least one patient staying > 6 h, 60% of the time there was at least one additional patient in the waiting room who could not be placed in an ED bed because none was open. The walk-out rate was 0.34 patients/hour when there were no patients staying in the ED > 6 h, vs. 0.77 patients/hour walking out when there were patients staying > 6 h in the ED (p < 0.001). When the ED contained more than 3 patients staying > 6 h, a trend was noted between increasing numbers of patients staying in the ED > 6 h and the percentage of time the ED was on ambulance diversion (p = 0.011). CONCLUSION In our ED, having both admitted and discharged patients staying > 6 h is associated with crowding.

Voluntarily Reported Emergency Department Errors

Objective: To describe voluntarily reported errors in an Emergency Department using a reward-based system. Methods: Prospective, observational study in urban, academic Emergency Department with 107,000 annual visits. All Emergency Department staff with direct patient contact voluntarily reported medical errors on a standardized form. Staff received

Evaluation of an Educational Video for Cardiac Patients

5 for each completed form. Rates were expressed with 95% confidence intervals (95% CI). Results: During 31 consecutive days, 9308 patients were cared for by 209 staff. Sixty-eight staff (33%) generated 209 reports, identifying 203 nonduplicative errors (22 per 1000 registered patients, 95% CI: 19, 25) on 183 patients. Nurses made 33% of the reported errors, physicians/physician assistants 22%, clerical staff 10%, technicians/orderlies 4%, non Emergency Department staff 19%, and unknown 12%. Error rates per 1000 hours worked were similar for nurses (6.6, 95% CI: 4.8, 8.0) and physicians/physician assistants (6.0, 95% CI: 4.0, 7.5). Staff activities at the time of the error were: ordering 23%, giving medication 9%, assessing patient 9%, registering patient 9%, doing procedure 8%, charting 6%, stocking 6%, filing 4%, and other 22%. Staff recovered 96 (47%) of the 203 errors before they impacted the patient: 60% by nurses and 34% by physicians and physician assistants. Patient impact for unrecovered errors were: no impact 29%, increased length of stay 56%, minor or potentially adverse events 11%, and major adverse events 4%. Conclusions: Half of reported Emergency Department errors are recovered, most often by nurses. The majority of unrecovered errors negatively impact patients, most often resulting in delays.

Development of an ED teaching program aimed at reducing prehospital delays for patients with chest pain

Prehospital delay is a major problem in the management of patients with acute cardiac ischemia. The authors created a patient teaching program consisting of an educational video and written instructions designed to reduce prehospital delays in patients with chest pain. Patients who received standard discharge instructions served as the control group, whereas those who received the new patient teaching in addition to standard discharge instructions served as the intervention group. Of the 500 enrolled, 19% were rehospitalized within 1 year. Analysis of rehospitalizations showed no significant difference between the two groups on the three outcome variables: percentage who presented within the first hour of pain, use of ambulance, and time from anginal onset to emergency department arrival. In a comparison of the index hospitalization to the rehospitalization, there was a significant increase in the use of ambulances for the intervention group, p = .03, but not for the control group.

BLOOD GLUCOSE MEASUREMENT IN PATIENTS WITH SUSPECTED DIABETIC KETOACIDOSIS :A COMPARISON OF ABBOTT MEDISENSE PCX POINT-OF-CARE METER VALUES TO REFERENCE LABORATORY VALUES

OBJECTIVE Delays in providing thrombolytic agents to patients with chest pain occur mainly in the prehospital arena. To reduce prehospital delay in treating patients with chest pain, we created a discharge teaching video that emphasized calling 911 in the event of a possible heart attack and a written action plan to be posted near the telephone. We also gave patients their EKG readings to bring with them on their next visit to the emergency department. SETTING AND SAMPLE All patients with chest pain admitted to the Chest Pain Observation Unit at Baystate Medical Center, Springfield, Mass, were eligible for this teaching effort. We tracked 127 nonconsecutive patients from January 1997 to May 1997. Of these patients, 108 were included in the study. RESULTS We interviewed 102 patients (94%) 3 days after they were discharged from the Chest Pain Observation Unit. Within this group, 92% were able to describe what a heart attack might feel like, and 81.4% said they would call 911 or go to the hospital if they had symptoms of a heart attack. If they thought that their symptoms might be indigestion, 69% said they would take an antacid, then go to the hospital if they did not feel better. Fifty-one percent remembered what to do with their EKG readings, and 60.7% knew how to take their nitroglycerin correctly. CONCLUSION We concluded that patients understood the message they were given and retained some of the material 3 days after discharge from the Chest Pain Observation Unit. The follow-up telephone calls revealed areas for improvement in the discharge teaching tools.

Physician vs patient assessment of dyspnea during acute decompensated heart failure

INTRODUCTION The purpose of this study is to compare blood glucose levels measured by a point of care (POC) device to laboratory measurement using the same sample venous blood from patients with suspected diabetic ketoacidosis (DKA). METHODS A descriptive correlational design was used for this IRB-approved quality assurance project. The study site was the 50-bed BMC emergency department (ED) which has an annual census of over 100,000 patient visits. The convenience sample consisted of 54 blood samples from suspected DKA patients with orders for hourly blood draws for glucose measurement. Spearman correlations of the glucose POC values, reference lab values, and differences between the two, were evaluated. A chi-square test was used to evaluate the association between the acidosis status and FDA acceptability of POC values. RESULTS Patient age range was 10-86 years; 63% were females; 46% had a final diagnosis of DKA. POC values underestimated glucose levels 93% of the time. There was a high correlation between the lab value and the magnitude of the difference, (lab minus POC value) indicating that the higher the true glucose value, the greater the difference between the lab and the POC value. A chi-square test showed no overall association between acidosis and FDA-acceptability. DISCUSSION The POC values underestimated lab reported glucose levels in 50 of 54 cases even with the use of same venous sample sent to the lab, which make it highly unreliable for use in monitoring suspected DKA patients.

Long-term follow-up and influence of symptom-free interval on restenosis after repeat percutaneous transluminal coronary angioplasty

This study assessed agreement between physician and patient self-reported measures of dyspnea severity during acute decompensated heart failure (ADHF). Both the physician and patient measured the change in dyspnea severity over 1 hour using 2 methods: (1) the difference of two static dyspnea measures (STATIC) and (2) a single transitional measure (TRANS). Likert scales and visual analog scales (VASs) were used. Data on 112 patients were analyzed. The mean difference between physician and patient VAS scores was 1 mm (limits of agreement: -54 to 56 mm) using the STATIC data. For TRANS data, the mean difference was 5 mm (limits of agreement: -75 to 86 mm). For the Likert scales, the weighted kappa was 0.13 and 0.23 for STATIC and TRANS data, respectively. The wide limits of agreement restrict our ability to substitute physician assessment for patient self-assessment of dyspnea in patients with ADHF.