Patient Safety in Emergency Care

Additional Statement, Submitted by Robert L Wears, M.D., M.S., Chair, Society of Academic Emergency Medicine Task Force on Patient Safety and Professor, University of Florida College of Medicine, Department of Emergency Medicine

Executive Summary

Emergency care affects large numbers of people—there are about 100 million emergency department (ED) visits per year, four times the number of surgical operations. However, errors in emergency care have not been studied in detail. What little is known suggests that errors in emergency departments (EDs) are common, and that the proportion of preventable adverse events occurring in EDs is among the highest for all care areas. Thus, better understanding of the nature of errors occurring in the ED could have a broad impact on the population.

In addition, the ED has some characteristics that serve to make it different from other care areas, and that may increase the propensity to err, and may make application of solutions developed for other areas problematic. This unique cognitive environment has hardly been investigated, and could provide additional fundamental insights into the way experts perform in dynamic, uncertain, time-pressured and shifting environments. Just as investigations of air traffic controllers, aircraft carrier operations, fire fighters, etc., provided generalizable insights into human performance, study of emergency caregivers could be leveraged to increase our general knowledge of how to improve human performance.

This testimony argues for a focused research and implementation effort to develop a deep understanding and rich description of the mechanisms of error occurring in emergency department settings, which should lead to fundamental, systematic, effective implementations for safety improvement. It cautions that emergency care has unique features with respect to patient safety and enhancing human performance, and so improvements there should not be assumed to result as a part of grand improvement strategies for health care as a whole.

The Problem

Although Bogner has pointed out that, "The emergency room, with its myriad activities and extreme time demands, ... is emerging as a candidate for error research"¹, little research has been conducted on safety in emergency care. There would be both public health and scientific value to be gained from research focused on emergency care errors.

Public Health Value. What little we know about patient safety in emergency care comes from three large retrospective studies on medical error (the Harvard Medical Practice Study (HMPS)^{2, 3} the Quality in Australian Health Care Study (QAHCS)^{4, 5}, and the Colorado-Utah study (CUS)^{6, 7}) that all found that a high proportion of preventable errors with serious consequences occur during care in the emergency department (ED). These results are even more remarkable when one considers that 80 percent of ED patients are not admitted to the hospital and thus were not even considered in these studies. The public burden of even a low level of injury could be enormous, since the volume of ED care is high—roughly 100,000,000 annual visits in the U.S.⁸, four times the number of surgical procedures. Thus, a better understanding of the nature of errors occurring in the ED could have a substantial public health impact. However, these three studies do not provide insight into the mechanisms of error and so do not provide a guide to effective interventions.

It is unlikely that the chart-based methods used in these studies would be effective in more specific investigation of ED errors, for at least three reasons. First, chart documentation in the ED is shorter and less detailed than the hospital chart. Second, many adverse events caused in the ED are not manifested immediately, and thus are recorded in locations other than the ED chart. For patients discharged from the ED, their site of follow-up care is frequently not known, and the follow-up caregivers are sometimes unaware of the previous ED visit. Finally, there is evidence that patients who experience problems in their ED care are less likely to return to the same ED for follow-up care, exacerbating the difficulty of locating the necessary documents to identify or review adverse events⁹. Therefore, new methods will be needed to gain insight in this area.

Scientific value. In addition to the potential public health benefits, investigation of safety in emergency care may have inherent scientific value. The bulk of fundamental safety research to date stems from a single setting, that of the anesthesiologist in the operating room. Although the lessons learned there about human performance are generalizable, it is not known how they might actually be manifested in other, very different settings.

The emergency department is a complex and difficult environment in which to provide medical care and differs substantially from more traditional settings in the organizational and cognitive burdens placed on caregivers. There are six aspects of ED care that make it qualitatively different from care rendered in more traditional settings, and likely make it more vulnerable to error. While all are present to some degree in any care area, their magnitude and combined presence in the ED give it unique characteristics that call for particular study, and may provide insights similar to those gleaned from study of expert performance in other uncertain, dynamic, and demanding domains.

The first factor is unboundedness. Unlike other care areas, which use either physical (number of beds) or administrative (staffing ratios) constraints to limit workload, the demand for emergency care has no upper bound. It has been remarked that, "The ED is the only infinitely expansible part of the hospital," alluding to the common practice of decompressing full inpatient and intensive care units by holding their patients in the ED, regardless of ED load.

The second factor is multiplicity. Emergency caregivers typically deal with many patients simultaneously; while this occurs in other settings, it occurs to a much greater extent in the ED. Multiplicity creates several problems. In combination with unboundedness, it creates a potential for cognitive overload, in that workers can only attend to a finite number of tasks simultaneously, while there are virtually no constraints to the number of patients or tasks emergency caregivers may face. Another aspect of multiplicity that heightens the complexity of ED care is the tremendous variability of clinical problems encountered. Emergency caregivers must simultaneously manage children and adults, surgical and medical complaints, life-threatening and trivial conditions. In addition, this creates the potential for new and unexpected interactions in the system, since the appearance of new patients or problems affects directly the resources available to deal with current patients and vice versa.

Third, emergency caregivers operate under much greater conditions of uncertainty than do those in other realms. This uncertainty takes three forms. There is primary uncertainty, in that each patient encounter is a novel one, and there is in general no limit to the types of problems that might be expected. A cardiologist, who can in general count on his or her next patient to have a heart problem, however unspecified, has a much smaller entropic burden than the emergency physician who can have no general expectation of the nature or severity of the next patient’s problem. A secondary level of uncertainty exists in that, as a specialty in breadth, not depth, it is difficult for emergency caregivers to acquire and maintain detailed and complete knowledge bases similar to those of traditional specialists. And, finally, ED care is given under a tertiary form of uncertainty, in that information that is known and present somewhere in the system is frequently unknown or unavailable to emergency caregivers at the time of the patient encounter. Current and past medications, allergies, results of past diagnostic evaluations, or the existence of pending ones are frequently unobtainable in current ED practice, or may only be obtained at a high opportunity cost.

Fourth, ED care is provided under severe time constraints. While production pressures are certainly present in other care areas, the time constraints of ED care are severe (clinicians typically must average between 4 to 6 patient dispositions per hour during peak times). This causes a narrowing of focus and a rush to judgment, creating both false positive and false negative errors in a form of speed-accuracy tradeoff. In addition, in some true emergencies, (e.g., upper airway obstruction), the window of opportunity for successful action is brief and physicians must rapidly commit to a course of action without waiting for greater certainty if they are to have any chance at success.

Fifth, emergency physicians routinely receive little to no feedback on the results of their care. Once a disposition is made, patients disappear from the ED into a void and are not seen again. Systems for returning outcome information to ED practitioners are uncommon to nonexistent. It would seem almost impossible for learning from experience to occur under such conditions.

Finally, there is little opportunity for practice in ED care. In many other domains, expert practitioners routinely perform their most dangerous tasks frequently. For example, pilots take off and land several times a day, anesthesiologists induce, intubate, and recover frequently, and surgeons operate daily, but in the ED the riskiest procedures (e.g., emergency intubation, cricothyrotomy, thrombolysis) are among the least commonly performed, sometimes on the order of monthly, yearly, or even less often.

These six factors are not the only ones that affect performance in the ED; for example, shift work, sleep loss, and heavy dependence on services outside the ED (laboratory, radiology, consulting services, etc.) also play a role.

Since the level of training and qualifications of emergency caregivers has increased dramatically in the past 20 years, the high rates of error in the ED would not seem to arise from less competent or committed practitioners, but rather from high levels of task complexity, uncertainty, multiplicity, and production pressures⁷. To paraphrase Rochlin¹⁰, for a caregiver in an emergency, unsure of context and pressed into action only when something has already gone wrong, with an overabundance of some data but missing the rest and under pressure to act quickly, avoiding a mistake may be as much a matter of good luck as good training. Research in this area could provide information critical to understanding the performance and characteristic errors of emergency caregivers, and should prove useful in devising effective interventions. This is important because in other settings, seemly logical, well-intentioned interventions have paradoxically made systems less resilient and more vulnerable to error when the context of work was not well understood^10-12. Thus, the extrapolation of safety innovations in other areas to the ED may not be assured of success. In addition, methods developed for the study of emergency care might prove useful in analysis of errors in other ambulatory settings, which have been little studied to date¹³.

What Is Known

There have been few focused investigations of errors and adverse events occurring in the ED, and even fewer into their nature, triggering and contributing factors. What is available in the literature offers tantalizing glimpses of the problem but does not provide a great deal of understanding into the origin, manifestation, recognition, prevention or mitigation of errors. There have been six main streams of research.

The first stream includes the three large epidemiological investigations previously mentioned that have identified significant rates of preventable error occurring in EDs. All were based on retrospective record reviews and were limited to hospital inpatients, who comprise less than 20 percent of all ED visits. Despite differences in methods and medical cultures, their results consistently show EDs to have a high rate of preventable errors with serious consequences. The Harvard Medical Practice Study^{2, 3} found 3 percent of all adverse events leading to injury occurred in the ED; 25 percent of those resulted in death or disability, 70 percent were judged negligent and 93 percent considered preventable¹⁴. In the Quality in Australian Health Care Study^{4, 5} the ED accounted for 1.5 percent of adverse event injuries; 82 percent of these were judged "highly preventable," the highest proportion in the study⁴. And in the Colorado-Utah study, ^{6, 7} the ED was responsible for 3 percent of adverse events, with 52.6 percent considered negligent. Of the adverse events attributed to the emergency physician, 95 percent were judged as negligent⁷. Because they dealt only with inpatients, and because typically over 80 percent of ED patients are not admitted to the hospital, these three studies provide only a "tip of the iceberg" glimpse at the problem of errors in the ED. Indeed, one of the most serious errors that can occur in an ED is failing to admit a patient who requires it, which could not be detected by chart review on admitted patients.

The success of the Australian Incident Monitoring Study¹⁵ inspired similar efforts in other specialties, including emergency medicine. A surveillance study based on both voluntary and mandatory reporting of ED incidents revealed that about 97 percent of the critical incidents were deemed preventable^{16, 17}. Analysis of factors contributing to these incidents suggested systems factors played a role in almost 80 percent, and provider factor in about 60 percent.

The second stream concerns studies on failure to admit patients in focused settings, such as acute cardiac ischemia. Lee⁹ reported that almost 4 percent of all patients presenting to the ED with chest pain due to acute myocardial infarction (AMI) were erroneously discharged home, and that on admittedly retrospective review, about half of these discharges were preventable. More recently, Pope¹⁸ reported that about 2 percent of patients suffering from AMI were mistakenly discharged from the ED, and that a similar proportion of patients with unstable angina was likewise erroneously discharged. Almost simultaneously, Collinson¹⁹ reported that about 7 percent of chest pain patients who were discharged from the ED had enzyme elevations consistent with prognostically important myocardial damage.

A third stream of investigation has involved analysis of malpractice litigation stemming from ED care. Karcz et al conducted a series of investigations on closed claims against EDs in Massachussetts^20-23. They concluded that eight diagnostic areas (chest pain, abdominal pain, wounds, fractures, pediatric fever, aortic aneurysm, CNS bleeding, and epiglottitis) accounted for about two-thirds of the indemnity dollars. Retrospective application of guidelines developed by her group for these eight areas might have prevented about 45 percent of these claims. However, many of the guidelines tended to involve better charting as a defense against litigation; the extent to which they would prevent adverse events or injury is not known. Rusnak²⁴ examined litigation resulting from missed diagnoses of acute myocardial infarction, and reported that physicians who missed diagnoses had less ED experience, misread more electrocardiograms, and tended to admit fewer patients to the hospital. Risser et al conducted another study of closed claims in eight EDs focusing on teamwork failures, and found an average of about 9 teamwork failures per case²⁵. They concluded that roughly half the deaths or injuries were preventable or mitigable through better teamwork and coordination among caregivers. Although the association between malpractice claims, adverse events, and preventable errors is weak²⁶, these results indicate areas that may be worth further study.

A fourth research stream has concentrated on emergency physician’s diagnostic performance in a variety of tasks such as interpreting radiographs or electrocardiograms. Much of this research seems to have a subtext of establishing or defending specialty boundaries (‘turf’) and is temporally related to the development of emergency medicine as a specialty and subsequent controversies about scope of practice^27-32. For example, in Europe and Asia, where emergency medicine is not as accepted as it is in the U.S., papers of this type are still common^33-36, whereas they seem to have declined in the U.S. literature.

There have been few studies of medication errors in EDs, which seems surprising since EDs frequently dispense medications using procedures that differ from the rest of the hospital. Selbst³⁷ reported a retrospective review of incident reports of medication and intravenous fluid errors in a pediatric ED. The most common errors were incorrect dose, or incorrect drug. Most of the latter errors were due to look-alike packaging or sound-alike names. Over half the errors involved no injury to the patient, and in this small sample, no patient suffered permanent injury or death.

Most of the studies mentioned so far have concentrated on active failures. Latent factors that might lead to errors in emergency care have hardly been studied at all. This is taken up in a fifth stream of investigation. Risser et al pointed out the importance of the social milieu of the workgroup^{25, 38}. Chisholm et al have broken new ground in investigating ergonomic conditions in the ED in a study on the frequency of task interruptions^{39, 40}. They reported that emergency physicians were interrupted on average about once every six minutes, and that two-thirds of the interruptions caused a change in task. Wears has called attention to common ergonomic deficiencies in emergency care workplaces⁴¹. Espinosa et al⁴² used a systems approach to re-engineer radiography systems in the ED and provide better feedback to the emergency physician and achieved an order of magnitude reduction in the rate of unmitigated adverse events.

Finally, a sixth stream, observational studies of emergency caregivers who are, in Hutchins’ phrase⁴³, "in the wild" are rare and have only recently begun to appear. In a study of the effect of teamwork training, Morey et al⁴⁴ used trained observers of emergency caregivers to record teamwork behaviors and task errors. They found a base rate of about one error for every five patient events (units of observation), and reported about a 50 percent decrease in observed task errors after teamwork training. However, they recorded little detail on the context of the errors that were observed. In related work, Lauer video-taped emergency caregivers in a complex task, rapid sequence intubation (RSI), and noted that task errors were common overall but highly variable in separate episodes, i.e., that some RSIs had large numbers of task errors while others had very few (Lauer, Perry, Wears, et al, unpublished data).

Boreham et al⁴⁵ conducted a prolonged observational study in two EDs in the United Kingdom, and paid particular attention to latent factors that set up emergency caregivers to err by using the critical incident technique^46-48. They identified three particularly important latent conditions: patients’ unrestricted access to the ED, cognitive errors by caregivers, and a disparity between the division of labor and working conditions caused by the strict horizontal and vertical division of labor in the ED.

What Is Needed

To summarize, the work done to date has concentrated on the "what"—the frequency and scope of errors in the ED. What is missing from these multiple streams of previous research is a rich description of the way errors occur, are recognized, prevented, or mitigated in clinical emergency care. In other words, what is needed is a better understanding of the "why" and the "how"—how well-intentioned, well-trained care-givers commit errors that in retrospect are thought to be avoidable. Boreham’s direct observations come closest to what is proposed in this study, but do not provide the narrative detail, and did not use multiple methods of data collection to enhance comprehensiveness⁴⁹.

A focused effort on understanding basic, underlying mechanisms affecting patient safety in emergency care settings is less likely to have immediate applicability than research focused on development and testing of specific remedies for identified safety problems. However, in the long run be it may be more powerful since a deeper understanding of which aspects of the system contribute to error (or to safety) could be used to guide deep and fundamental changes in the processes of care⁵⁰. An organized effort could facilitate the transition between basic research on mechanisms and research on solutions and implementations.

In addition, a focused effort could result in the extension of existing analytic frameworks (e.g., Andrews⁵¹, Vincent^52-54, Reason^55-56, Shapell⁵⁷) for the investigation of critical incidents by incorporation of cognitive, or decision-making factors. These frameworks tend to concentrate on organizational and contextual factors, but do not cover cognition or decision-making as thoroughly. By adapting them to make them specifically applicable to emergency care settings, this extended framework could then serve as a template for future tools to be used in other ambulatory settings. And finally, information on the quality and quantity of information gained by the different methods proposed here could be immediately useful to other safety researchers in other domains.

The emergency care community has only recently become open to the insights from the "New Look" at patient safety⁵⁸. The major professional organizations (ACEP, SAEM, ENA) have all appointed task forces to examine safety issues in their respective domains, and have further agreed in principle to coordinate their efforts. A major journal, Academic Emergency Medicine, sponsored a Consensus Conference on Patient Safety in May 2000, which began to develop agendas for improvement in education, research, and patient care, and which specifically called for safety research targeted at emergency care settings⁵⁹. Thus, a focused effort should find a receptive audience among emergency caregivers.

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Current as of September 2000

Internet Citation:

Patient Safety in Emergency Care. Additional Statement by Robert L. Wears National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/aswears.htm

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