Patient Safety in the Emergency Department

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Chapter 70 Patient Safety in the Emergency Department

Melanie Pitone, MD, FAAP, Steven M. Selbst, MD, FAAP, FACEP

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?

1 Time pressures

2 Incomplete medical and drug histories available

3 Unscheduled care

4 Inconsistency of patient arrival

5 High-risk patients (high acuity)

6 Environment in flux—patients have varied locations (rooms, x-ray, hallway)

image 24-hour activity
image No time to restore order and “reset” the environment
image Circadian rhythm of staff is challenged
image Transition of patient care among staff (consultants and change-of-shift)

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?

image Variety of patient size and age

image Need to calculate most medication doses

image Limited time for pharmacist review of medication orders

image Stressful/demanding environment

image ED overcrowding

image Fatigue (nurses and physicians)

image 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?

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