Patient safety in the emergency department : errors, interruptions and staff experience

Abstract

International studies have reported that injuries and complications during hospital admissions affect nearly 1 in 10 patients and that up to 50 % are the direct result of errors and therefore preventable. In Sweden, the figures are similar. The often cited report, To err is human – building a safer health system by the Institute of Medicine (IOM) emphasises the system approach in preventing future errors by designing safety into systems and not to blame individuals for past errors. This approach has also been implemented into the Swedish healthcare system through the Patient Safety Act and through the formation of a new agency in 2013, the Health and Social Care Inspectorate (IVO). Emergency departments (EDs) have a front position in Swedish healthcare in that a high percentage of patients have their first contact with hospital care in EDs. The ED environment has been described as complex and dynamic and one in which errors often occur. Research on patient safety in the ED has increasingly grown, with recent findings indicating that crowding, interruptions and multitasking all contribute to errors. However, there remains little knowledge on patient safety in Swedish EDs.

The overall aim of this thesis was therefore to increase our knowledge about errors, interruptions and staff experience of patient safety risks in the ED. The specific aims in paper I and II were to describe the incidence and types of reported errors and complaints in ED care and their contributing factors. In paper III the aims were to explore interruptions occurring during common activities of clinicians and their perceptions of interruptions. The final paper was designed to describe physicians and registered nurses’ (RNs) perceptions and management of patient safety risks in the ED.

In this descriptive project qualitative and quantitative data were collected from national registries and through observations of and interviews with ED clinicians. Data were analysed using qualitative content analysis and non-parametric statistics.

The results represent the frequencies and characteristics of reported errors and complaints in Swedish ED care. The overall result shows that the most common errors that care providers, healthcare staff and patients reported were those concerned with diagnostic procedures, treatments and organisational matters. The contributing factors to errors in cases reported to the National Board of Health and Welfare were multifactorial: the most common contributing factor was human error that occurred most often during diagnostic procedures, followed by factors in the local environment. Interruptions took place most often on a face-to-face basis and during information exchange. Preparation of medication was the most interrupted activity in relative terms. Interruptions were not always perceived as negative, and negative feelings of interruptions were related to a disturbed work process. The physicians and RNs perceived high workload as the main patient safety concern in the ED. The most common strategy to prevent errors was to check and double check. Because the RNs felt responsible for managing patient safety risks, they reported using a strategy of taking command and control if they felt that patient safety was in jeopardy.

The level of information detail varied and was sometimes missing in the different national and local registries. Further, we found that internal investigations and root cause analysis were sometimes missing entirely. These shortcomings constitute a risk of missing important patient safety risks and limit the development of solutions that can improve such safety. Latent conditions, such as high workload, were rarely identified and interruptions were ever identified as a contributing factor in cases reported to the National Board of Health and Welfare. The clinicians perceived high workload as the main patient safety concern in the emergency department. Interruptions during high workload were seen as increasing the risk for communication and medication errors. Some RNs taking command and control when patient safety was threatened indicating that RNs may play an important role in patient safety.