1 How extensive is the problem of medical errors in the emergency department (ED)?

The Institute of Medicine (IOM) estimated in 1998 that 44,000 to 98,000 deaths per year are due to medical errors. These data make medical errors the eighth leading cause of death. Medical errors in the United States cost $2 billion each year. The number of deaths noted above has been disputed, and some of the adverse events included in the above report may not have been due to medical error. However, the problem is significant. It is not known how many errors in the IOM report involved delivery of care to children in the ED. Many of these errors are preventable.

Bates DW, Spell N, Cullen DJ, et al: The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Group. JAMA 277:307–311, 1997.

Kohn LT, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System. Washington, DC, Institute of Medicine, National Academy Press, 1998.

2 Which factors inherent to the ED contribute to medical errors?

Schenkel S: Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med 7:1204–1219, 2000.

3 What is a latent error?

Latent errors are design flaws or failures in the tools or systems and work environment that produces circumstances in which a worker (nurse, physician) is likely to err. Latent errors may persist for long periods of time before they are discovered and corrected.

4 Why are children in the ED at particular risk for error?

Variety of patient size and age

Need to calculate most medication doses

Limited time for pharmacist review of medication orders

Stressful/demanding environment

ED overcrowding

Fatigue (nurses and physicians)

Miscommunication (with patients or among staff)

Seriously ill pediatric patients are at greatest risk for error in the ED.

Chamberlain, JM, Slonim A, Joseph JG. Reducing errors and promoting safety in pediatric emergency care. Ambul Pediatr 4:55–63, 2004.

Selbst S, Levine S, Mull C, et al: Preventing medical errors in pediatric emergency medicine. Pediatr Emerg Care 20:702–709, 2004.

5 How common are medication errors in the United States?

The IOM report found that 20% of errors involved medications and the majority (75%) of these occurred at the physician ordering stage. Medication errors are the second most frequent and second most expensive precipitant of medical malpractice claims. About 42% of claims involving medication errors result in significant permanent injury, and 21% result in death. It is estimated that preventable adverse drug events cost U.S. hospitals $2 billion annually, not including malpractice costs. In a study by Kozer et al, 10% of all patients seen in a pediatric ED had a prescribing error. In a study by Taylor et al, almost 60% of prescriptions written in a pediatric ED contained an error.

Kohn LT, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System. Washington, DC, Institute of Medicine, National Academy Press, 1998.

Kozer E, Scolnick D, Macpherson A, et al: Variables associated with medication errors in pediatric emergency medicine. Pediatrics 110:737–742, 2002.

Physicians Insurers Association of America. Medication Errors Study. Philadelphia, Physicians Insurers, 1993, pp 1–44.

Taylor BL, Selbst SM, Shah AEC: Prescription writing errors in the pediatric emergency department. Pediatr Emerg Care 21:822–827, 2005.

6 What are the most common types of medication errors in a pediatric ED?

Medication dosing errors are the most common type. Pediatric medicines, for the most part, have weight-based dosing. Incorrect recording of weight or incorrect calculation of dose results in the largest amount of error. This can lead to severe morbidity because often the mistake is a “tenfold error” because of a misplaced decimal point. Giving an incorrect drug is the next most common type of medication error. This is usually due to similar packaging of drugs or medication names that sound alike. Administration of a medication to a child with a known allergy to the medication is another common type of medication error.

Kozer E, Scolnick D, Macpherson A, et al: Variables associated with medication errors in pediatric emergency medicine. Pediatrics 110:737–742, 2002.

Selbst S, Fein JA, Osterhoudt K, et al: Medication errors in a pediatric emergency department. Pediatr Emerg Care 15:1–4, 1999.

7 What is the most common outcome of medication errors in the pediatric ED?

Most commonly, no harm is done. There is, however, potential risk of prolonged hospital stay, additional care required, and death.

Selbst S, Fein JA, Osterhoudt K, et al: Medication errors in a pediatric emergency department. Pediatr Emerg Care 15:1–4, 1999.

KEY POINTS: MEDICATION ERRORS IN THE PEDIATRIC ED

1 The largest threat to children in the ED is medication errors, most of which are dosing errors.

2 The ED environment is a challenge, largely because of its unstructured and hurried environment, with patients presenting with unpredictable issues, with varied patient size and levels of urgency, and at unscheduled times.

3 Better ED systems, communication, and teamwork can reduce errors. Knowing the risk of errors is a big first step.

8 When are errors most likely to occur in a pediatric ED?

Evening shift and overnight—specifically 4 am to 8 am. Fatigue, severity of patient illness, and less supervision of trainees are theoretical reasons for this trend.

Kozer E, Scolnick D, Macpherson A, et al: Variables associated with medication errors in pediatric emergency medicine. Pediatrics 110:737–742, 2002.

Selbst S, Fein JA, Osterhoudt K, et al: Medication errors in a pediatric emergency department. Pediatr Emerg Care 15:1–4, 1999.

9 What is a transition? What makes it a risk in emergency medicine?

Transition is the transfer of care between care providers. It is also known as “change of shift.” Transitions in the ED interrupt continuity of care and are a source of potential error. Few studies have described transitions or promoted safe transition practices. Communication errors can result from the poor transfer of information and also from the transfer of poor information. Staff should be educated on the risks created by the transfer of a patient’s care, and best practices for safe transitions should be promoted.

Beach C, Croskerry P, Shapiro M: Profiles in patient safety: Emergency care transitions: Acad Emerg Med 10:364–367, 2003.

10 Why are children with special health care needs vulnerable to error in emergency care?

Children with special health care needs are a growing population representing 16–18% of children in the United States. They are at risk for medical error in the ED for several reasons:

Some of their problems are occult and difficult to recognize, thus delaying care.

Some conditions are recognizable but refractory to standard therapy, thus delaying receipt of the best care for that particular patient.

Their baseline condition (e.g., vital signs, mental status) may not be known to the ED provider. Thus, severity of illness can be underestimated or overestimated.

They often have rare conditions that are unfamiliar to the emergency care provider.

Many require technologic devices that are not available to the ED providers.

Sacchetti A, Sacchetti C, Carraccio C, et al: The potential for errors in children with special health care needs. Acad Emerg Med 7:1330–1333, 2000.

11 What can be done to make children with special health care needs safer when receiving emergency care?

An emergency information form, promoted and conceptualized in part by the American College of Emergency Physicians and the American Academy of Pediatrics, can help ED physicians provide more efficient and appropriate care to children with special health care needs. The form may contain contact information, past medical history and procedures, common presenting problems, and suggestions for management strategies. Coupled with medical identification jewelry and electronic information transfer, the emergency information form has the potential to improve safety for this at-risk group.

Sacchetti A, Sacchetti C, Carraccio C, et al: The potential for errors in children with special health care needs. Acad Emerg Med 7:1330–1333, 2000.

12 When caring for a patient with limited English proficiency in the ED, would a family member interpreter be sufficient?

No, it would not be ideal. In one pediatric study, one clinical encounter generated 31 errors in medical interpretation. Most errors were of omission and had potential for clinical consequences. Errors committed by ad hoc interpreters (hospital staff, family members, other patients in the ED) as opposed to hospital interpreters were more likely to have clinical consequence. The legal liability of not ensuring appropriate interpretation is large. A $71 million lawsuit was generated by one misinterpreted word in the ED. One family was separated by social services for misinterpretation in a child abuse case. Efforts should be made to provide reliable, professional interpretation for ED patients and families.

Flores G, Laws MB, Mayo SJ, et al: Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 111:6–14, 2003.

13 Why would physicians conceal a medical error?

The medical profession values perfection.

The doctor may feel shame or guilt.

The doctor may fear damage to reputation and decreased income.

There is a need to maintain trust with the patient/family.

There may be pressure from administration or other parties.

There is often fear of punishment.

There is often fear of a malpractice lawsuit.

Finkelstein D, Wu AW, Holtzman NA, et al: When a physician harms a patient by a medical error: Ethical, legal and risk management considerations. J Clin Ethics 8:330, 1997.

Selbst SM: The difficult duty of disclosing medical errors. Contemp Pediatr 20:51–63, 2003.

14 Are physicians obligated to disclose medical errors to patients?

The American Medical Association Code of Ethics guidelines for professional conduct states: “The physician is ethically obligated to inform the patient of all the facts necessary to ensure understanding of what has occurred when a patient experiences a significant medical complication from a mistake.” Disclosure regarding minor errors with little consequence is not specifically addressed. Several studies have found that patients and parents want the physician to disclose a medical error. Patients want the physician to apologize for an error. Families should be assured that everything is being done to discover how the error occurred and to prevent it from happening again.

American Medical Association, Council on Ethical and Judicial Affairs: Code of medical ethics: Current opinions with annotations. Chicago, IIl. American Medical Association 1997; Sect. 8. 12:125.

Gallagher TH, Waterman AD, Ebers AG, et al: Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 289:1001–1007, 2003.

15 Is disclosure of a medical error likely to lead to a malpractice lawsuit?

Most patients, when asked, would be more likely to distrust a doctor, take their care elsewhere, or bring a lawsuit against a physician who conceals an error as opposed to one who is truthful and forthcoming with information. In Hobgood’s survey of parents who presented to an ED with a child, 99% wanted disclosure of hypothetical errors presented to them in scripted scenarios. Only 39% said they wanted the doctor to be reported to a disciplinary board because of the hypothetical error. Thirty-six percent said they were less likely to sue if the physician informed them of the error. However, if parents thought the error was severe, their desire for legal action was less amenable to reduction by disclosure.

Hobgood C, Tamayo Aarver JH, Elms A, et al: Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics 116:1276–1286, 2005.

Whitman AB, Park DM, Hardin SB: How do patients want physicians to handle mistakes? Arch Intern Med 156:2565–2569, 1996.

16 How should an ED physician approach a family after an error is discovered?

Investigate the problem first: Make sure there was an error.

Follow hospital policy. Discuss the case with risk management according to policy.

Find an appropriate time (when the family might be less stressed) and place (quiet area) to talk with the family.

Sit with the family and speak at eye level.

If an error is uncertain, advise the family that the event will be investigated.

If a mistake is certain, apologize. Say you are sorry.

Be plausible; do not mislead the parents or patient.

Avoid placing blame on others.

Reassure the family that any effects of the error will be managed to mitigate harm to the child.

17 What can be done to prevent errors in a pediatric ED?

Errors and error prevention must be addressed instead of hidden. An environment that encourages staff to detect and report errors is crucial. An environment that blames individuals hinders the reporting process. Physicians and administrators must focus on systems that lead to error. Medical errors are rarely the result of one individual and are most commonly due to the ED process. The system must be designed to decrease the likelihood of an error reaching the patient.

Address workforce fatigue issues. Ensure quiet areas for calculation and drawing-up of medications, and develop a system to allow for independent double-checking of medications. Use only approved abbreviations. Write the patient’s weight and allergies in a clearly visible location, perhaps near the medication orders and on prescriptions for verification. Encourage staff to be less defensive and more receptive to helpful feedback. Carefully mentor and monitor trainees. Emphasize good communication skills to staff. Analyze “near-misses” (Table 70-1).

Table 70-1 Preventing Medication Errors in the Emergency Department

1 Educate physicians, nurses, pharmacists, and manufacturers about potential errors.

2 Create systems in the emergency department to make errors less likely.

Remove dangerous medications that are rarely used from emergency department shelves. For example, since tetanus immunoglobulin is rarely needed and sometimes confused with tetanus toxoid, do not keep this drug in the emergency department. When needed, order it from the hospital pharmacy.

Reduce the noise level in the area where medications are drawn.

Reduce calculations for drug ordering as much as possible. Use length-based tapes or books with precalculated doses based on the patient’s weight.

3 Avoid abbreviations (such as q.d.) in drug ordering as much as possible.

4 Always place a zero before a decimal point (such as 0.5 mg), and avoid use of a terminal zero (such as 5.0 mg). Misinterpretation could result in a tenfold error.

5 Highlight patient drug allergies in the record.

6 Record weights of pediatric patients clearly and only in kilograms.

7 Note the child’s weight in an easily located area of the medical record, perhaps near where orders are written.

8 Consider computerized order entry to help reduce computational errors and errors related to patient allergies.

9 Welcome a nurse or pharmacist who questions an order. Do not act defensively or refuse to investigate a possible error.

10 Consider bar coding of medications.

11 Consider using an automated drug dispensing system.

Selbst S, Levine S, Mull C, et al: Preventing medical errors in pediatric emergency medicine: Pediatr Emerg Care 20:702–709, 2004.

Wears RL, Leape LL: Human error in emergency medicine. Ann Emerg Med 34:370–372, 1999.

18 How does Computer Physician Order Entry (CPOE) affect patient safety?

CPOE, the process by which orders for patient care are directly entered into the computer by the treating physician, can improve patient safety by making medication ordering safer. The software can provide physician decision support, check allergies and weights, and eliminate transcription errors. CPOE avoids omitted information on generated prescriptions, and the prescriptions can be sent electronically to a given pharmacy, enhancing efficiency. Implementation of CPOE in one intensive care unit setting decreased medication errors by 99% and adverse drug events by 40%. Unfortunately, there can be new types of errors inherent in the system. Drug alerts may be overridden because of the frequency of inexact allergy matches conveyed. There can also be adverse events if allergy information is not updated, or if the patients’ weight is entered incorrectly. CPOE has not been well studied in the ED setting.

Hsieh T, Kupperman G, Jaggi T, et al: Characteristics and consequences of drug allergy alert overrides in a computerized physician order entry system. J Am Med Inform Assoc 11:482–491, 2004.

Potts A, Barr F, Gregory D, et al: Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 113:59–63, 2004.

19 What are potential causes for patient misidentification?

Similar or same patient names

Language barriers

Patient answers to wrong name

ID bands removed

ID bands illegible or incorrect

Lack of patient ID process or failure to comply

O’Neill K, Shinn D, Starr K: Patient misidentification in a pediatric emergency department: Patient safety and legal perspectives. Pediatr Emerg Care 20:487–492, 2004.

20 How is patient safety taught to physicians in training?

Professional societies have been challenged by the Committee on Quality of Health Care in America to develop curricula to teach patient safety routinely, and include such knowledge in certification requirements. The Patient Safety Task Force of the Society for Academic Emergency Medicine has developed a suggested curriculum for this mission. Guidelines and case-based examples are available on their website (www.saem.org).

Cosby K, Croskerry P: Patient safety: A curriculum for teaching patient safety in emergency medicine. Acad Emerg Med 10:69–78, 2004.

21 What resources are available?

Agency for Healthcare Research and Quality (AHRQ) (www.ahrq.gov/qual): A division of the U.S. Department of Health and Human Services with a mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

National Guideline Clearinghouse (www.guideline.gov): A public resource for evidence-based clinical practice guidelines and an initiative of the AHRQ. Search terms can be entered.

National Patient Safety Foundation (www.npsf.org): Nonprofit organization devoted to understanding patient safety issues and how to improve them, as well as promoting public awareness and fostering communication.