Citation

Gill S, Mills PD, Watts BV, Paull DE, Tomolo A. J. Patient Saf. 2021; 17(8): e898-e903.

Copyright

(Copyright © 2021, Lippincott Williams and Wilkins)

DOI

10.1097/PTS.0000000000000636

PMID

32084094

Abstract

BACKGROUND: Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety.
OBJECTIVES: The aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them.
METHODS: Retrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015-2016) were coded by event type, root cause, and recommended actions.
RESULTS: One hundred forty-four cases were included for analysis. The most common adverse events were as follows: delays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%).
DISCUSSION: Root cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.

Language: en

Keywords

Humans; United States; Retrospective Studies; Emergency Service, Hospital; United States Department of Veterans Affairs; Veterans Health; Root Cause Analysis