Elsevier

Annals of Emergency Medicine

Volume 60, Issue 5, November 2012, Pages 555-563.e20
Annals of Emergency Medicine

Patient safety/original research
Safety Climate and Medical Errors in 62 US Emergency Departments

https://doi.org/10.1016/j.annemergmed.2012.02.018Get rights and content

Study objective

We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs.

Methods

We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors. We also obtained surveys from 3,562 staff randomly selected from each ED; survey data were used to calculate average safety climate scores for each ED.

Results

We identified 402 adverse events (incidence rate 4.1 per 100 patient visits; 95% confidence interval [CI] 3.7 to 4.5) and 532 near misses (incidence rate 5.4 per 100 patient visits; 95% CI 5.0 to 5.9). We judged 37% of the adverse events, and all of the near misses, to be preventable (errors); 33% of the near misses were intercepted. In multivariable models, better ED safety climate was not associated with fewer preventable adverse events (incidence rate ratio per 0.2-point increase in ED safety score 0.82; 95% CI 0.57 to 1.16) but was associated with more intercepted near misses (incidence rate ratio 1.79; 95% CI 1.06 to 3.03). We found no association between safety climate and violations of national treatment guidelines.

Conclusion

Among the 3 ED conditions studied, medical errors are relatively common, and one third of adverse events are preventable. Improved ED safety climate may increase the likelihood that near misses are intercepted.

Introduction

Medical errors are a major cause of morbidity and mortality in the United States. The Institute of Medicine's report To Err Is Human estimated that adverse events occurred in 2.9% to 3.7% of 33 million hospitalizations and that 44,000 to 98,000 people die each year as a result of medical errors.1 Previous safety studies have focused on medical errors in the inpatient,2, 3, 4 outpatient,5 critical care,6 and long-term care settings.7 Emergency department (ED) care is considered especially prone to medical errors for several reasons, including the fast pace and frequency of complex and life-threatening conditions. Moreover, as documented in another Institute of Medicine report,8 the nation's EDs face serious challenges, such as crowding, that may increase the likelihood of errors. Although there are data on medication errors in the ED,9 there are sparse data on the overall incidence of medical errors in the ED. A single-ED study interviewed staff during a 7-day period and found that 18% of 1,935 patient visits had self-reported errors.10 A more recent ED interview study showed that 32% of 487 visits had at least 1 “nonideal” care event.11

Traditional approaches to identifying and preventing the causes of errors (eg, root-cause analysis) are often passive and emphasize individual factors.12 Active surveillance of frontline health care providers about systems factors that may cause errors is an innovative strategy for identifying correctable causes of errors.13 Likewise, the overall “ED safety climate”—by which we mean both human factors and measureable attributes of the systems of care, not outward manifestations of safety culture—is a potentially useful proxy for safety. However, the link between ED safety climate and actual medical errors is unknown.

We conducted the National Emergency Department Safety Study to address these major gaps in the patient safety literature. The objectives of National Emergency Department Safety Study were to describe the incidence and types of medical errors in EDs and to assess the validity of a survey instrument that directly identifies systems factors thought to contribute to errors in EDs. We hypothesized that better ED safety climate, as measured by our instrument, would be associated with lower incidence of preventable adverse events and higher incidence of intercepted near misses. By contrast, we expected no association between ED safety climate and nonpreventable adverse events or nonintercepted near misses.

Section snippets

Study Design and Setting

Details of the National Emergency Department Safety Study design and data collection have been previously published.14 In brief, it was a multicenter study that sought to characterize both human and systemic factors associated with the occurrence of errors in the ED. The study was coordinated by the Emergency Medicine Network (http://www.emnet-usa.org). We invited EDs affiliated with the network to participate in the study, with additional recruitment through postings on emergency medicine

Results

The 62 study EDs were located throughout the country, had large annual visit volumes, and cared for many patients with each of the 3 conditions (Table 1). All of the EDs were urban and most (77%) were affiliated with an emergency medicine residency program. The overall ED clinicians' perceptions of ED safety climate were represented by a mean safety score of 3.5 on a scale of 1 to 5. The ratings appeared lower for 4 subscales: physical environment, staffing, information coordination and

Limitations

Our study has several potential limitations. First, because most participating EDs are urban academic centers, the results may not be generalizable to other settings. Second, we did not sample all ED visits, so we are unable to estimate the incidence of errors for all ED conditions. Third, although the reliability of initial physician judgments was similar to that of previous studies, in which κ statistics have ranged from 0.2 to 0.6,3, 4 only 3% of charts produced rater disagreement that

Discussion

In this study of 9,821 patients presenting to 62 EDs with 3 common conditions, the incidence of adverse events was 4.1%, of which 37% were deemed preventable. Although our measure of ED safety climate was not associated with a statistically significant decrease in preventable adverse events, it was associated with a higher likelihood of intercepted near misses. Last, there was no association between ED safety climate and serious violations of national treatment guidelines.

The National Emergency

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  • Cited by (0)

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was supported by grant R01 HS013099 from the Agency for Healthcare Research and Quality (Rockville, MD).

    Please see page 556 for the Editor's Capsule Summary of this article.

    Supervising editor: David L. Schriger, MD, MPH

    Author contributions: CAC, PDC, JAG, EG, RK, DJM, SRR, and DB conceived and designed the study. DB obtained research funding. CAC, AFS, JAG, DJM, and DB collected the data. CAC and C-LT analyzed the data and drafted the article. All authors contributed substantially to article revision. CAC supervised the study and takes responsibility for the paper as a whole.

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    Members of the Emergency Medicine Network and the principal investigators at the 62 participating sites are listed in the Appendix.

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