Patient Safety in the Emergency Department
Patient Safety in the Emergency Department
Approximately 250,000 preventable hospital deaths occur each year, making medical error the third leading cause of death in the United States. The fast-paced, quick-thinking environment of the ED, combined with often sick and complex patients in need of immediate care with little-to-no known medical history, can lead to increased risk of such medical error and adverse events.
While a busy ED environment sounds like an invitation for error, adverse events in the ED are as equally preventable as less chaotic clinical environments. Two-thirds of known errors are attributed to system-wide issues, not exclusive ED issues. Hospitals and health systems nationwide have made significant progress in identifying and improving patient safety outcomes over the past decade. Many continue to work tirelessly to create new systems and maintain effective systems that promote the delivery of high-quality care focused on a culture of safety and positive patient outcomes.
Patient Safety Awareness Week is recognized each year as a way to promote and encourage education of patient safety and the impact it has on all individuals across the continuum of care. In honor of this event, Mike Lipscomb, MD, Chief Quality and Patient Safety Officer, provides a brief overview of key focus areas and tips to help maintain a patient safety centered culture in the ED.
1. Event Reporting
Establishing an environment that promotes event reporting is a critical component of patient safety. An individual is less likely to report a mistake if he or she fears it will result in a negative consequence.
Leadership support is often the driving force encouraging team members to report adverse events and near misses. In the event of a mistake, leadership should take a positive focus on correcting the process, rather than a punitive decision for an individual. A “no blame” environment allows clinicians and other team members to be more comfortable in the practice setting which improves efficiency and increases the likeliness of mistake reporting.
Regular communication highlighting adverse events and near misses from department leadership is essential for the success of a department. Together the team can look at what occurred, how and why it occurred, and develop a solution to prevent a repeated occurrence. This focus on correcting the system leading to the error leads to a positive impact on patient outcomes rather than the negative impact of punishing a single individual, which uncommonly corrects the problem.
2. Electronic Health Records
The use of electronic health records (EHR) has been widely adopted in EDs nationwide over the past decade. These systems are intended to provide secure, standardized and well-documented patient records and in many ways have greatly improved care. However, these new technologies have also introduced opportunities for error.
The complexity of an EHR interface can easily hinder a clinician’s ability to perform simple documentation needs. Poor data display, complicated navigation and disconnected user-to-EHR workflows significantly increase the risk of error. When these disruptions are present, it is not uncommon for a clinician to develop unsafe workaround habits. Additional interface issues include alert fatigue, communication failure, misidentification of orders and inability to retrieve information, which all increase the chance of an adverse event.
To combat these issues, ED leadership should designate at least one member of the core team as an EHR champion who serves as the department expert and liaison with the information technology (IT) department. The champion must be knowledgeable of all technical functions in the interface and able to identify where pain points occur in the different interface processes. This person should be able to present areas for improvement and build solutions in collaboration with the IT team.
When safety or technology issues arise, the EHR champion serves as the main source of communication between both departments and ensures all necessary corrective action is taken. This role’s hands-on approach and regular communication is vital for the success and improvement of EHR-related safety.
3. Medication Safety
As many as 8% of patients in the ED have the potential for medication error as something “goes wrong” with the overall process of getting medication to a patient. More than 90% of these issues are intercepted before delivery to a patient, and of those that aren’t caught, not all of these will lead to patient harm. However, ED clinicians treat a number of patients simultaneously and regularly access high-alert medication leading to a high potential for harm for the few incorrect medications that are administered to the patient.
The use of a wide range of medications, different dosages appropriate for age, weight and gender and multiple routes for administration can be easily confused by a clinician treating a high volume of patients. Instances where patient names are similar, patient conditions are similar and look-alike/sound-alike drugs are prescribed, all add to safety risks.
The addition of an EHR champion helps with standardizing interface workflows to decrease improper medication selection. Adding a pharmacist to the ED is an extra layer of security which drastically improves medication safety and decreases error.
Medication error is 13 times less likely to occur with a pharmacist on duty in the ED. When a pharmacist is on duty, he/she is able to manage medication dispensing cabinets lessening the chance of dispensing a wrong medication. The pharmacist also provides more timely administration of medication, direct bedside consultation, and is more likely to intercept prescription errors before a patient receives a medication. He/she uses the most recent evidence to support medication orders and ensures best practices are used among the ED team.
4. Transition of Care & Admissions
During a shift change, ED patients waiting to be admitted or those still under evaluation transition to the oncoming clinician. Appropriate use of a transition protocol can decrease risk for adverse events. Conversely, simple missteps or lack of communication can result in the loss of important information about a patient’s evaluation which may lead to improper disposition or wrong diagnoses.
A standardized protocol for clinician-to-clinician transition in the ED is necessary to help avoid opportunities for increased error. This protocol should outline the appropriate actions for each step in the transition process and be evaluated regularly for areas of improvement. Four main stages are defined when building a standardized protocol in the ED:
- Pre-transition: When the initial clinician reviews a patient’s chart and finalizes any next steps for the oncoming clinician.
- Arrival of new clinician: The arrival of an oncoming clinician signals the start of a new shift.
- Initial and Oncoming Clinician Meeting: All important information is verbally communicated to the oncoming clinician and should follow a standard outline for discussion. This includes a patient summary, diagnostic test or labs for follow-up and a contingency plan.
- Post-transition: This stage is performed by the oncoming clinician when any items related to a patient’s care are finalized to ensure the treatment plan is completed.
One of the most impactful ways to improve the safety of transition is to limit the number of clinician handoffs. When the initial clinician dispositions his/her own patients, the opportunity for error significantly decreases. Building a schedule with overlapping shifts allows the initial provider time at the end of his/her shift to complete care of his/her patients.
Another way to improve transition safety includes eliminating distractions during clinician hand-off. This allows for the oncoming provider to ask questions and the initial provider to give the proper overview of care and address any action items. Additionally, creating an end-of-transition signal notifies the end of care from the initial clinician and the start of care from the oncoming clinician.
Not only does a standardized ED clinician-to-clinician transition protocol help eliminate error but also a standardized ED clinician-to-inpatient clinician transition does as well. Best practices in the admission process include verbal communication of vital information, patient ED course, pertinent lab and diagnostic test results, follow-up studies, as well as the opportunity for the admitting provider to ask follow-up questions. The Joint Commission’s Transitions of Care Portal offers resources and tools to help improve and formalize this process.
Not all patients who enter the ED are admitted. Patients who are discharged home should fully understand their diagnosis and how to get better. For the clinician, this means communicating several key items to the patient, both verbally and written, including a detailed explanation of the diagnosis, treatment received while in the ED, specific instruction on steps to take at home to complete the treatment plan, and warnings signs for when to return to the ED.
In addition to the verbal and written explanations, the clinician should provide the patient with the opportunity to ask questions or address specific concerns. The clinician should be confident the patient fully comprehends his or her diagnosis, treatment received and follow-up instructions.
A safe discharge process is not unique to the emergency department. Inpatients also require a safe discharge process. ApolloMD recently created two measures that support best practices in the discharge process for inpatients (HMIQ 001 and HMIQ 002). These measures address the completion of the discharge summary and follow-up care coordination in the discharge summary. To learn more about these measures, click here.
The opportunity for error has a higher presence in the ED compared to most other clinical settings, but that does not mean it has to occur. Utilizing the strategies mentioned above to establish a culture of safety and with the commitment of a dedicated team, we will continue to improve safety in our often hectic and fast paced Emergency Departments.
Dr. Michael Lipscomb began practicing emergency medicine in 1997 as a Clinical Instructor for the University of Michigan. In 2000, he joined ApolloMD at North Fulton Hospital, becoming medical director of the department in 2005. Dr. Lipscomb has served on multiple committees at the hospital and most recently completed terms of Secretary Treasurer and Chief of Staff, and continues to serve on the Medical Executive Committee. In 2013, ApolloMD was excited to welcome Dr. Lipscomb to the corporate team to oversee clinical operations of hospitals in the Southeast. With extensive experience in optimizing emergency department flow, EMR use, and patient satisfaction, Dr. Lipscomb became Chief Quality Officer for ApolloMD in 2016. Dr. Lipscomb received his medical degree from The University of Texas Southwestern Medical Center at Dallas, then completed training in Emergency Medicine at The University of Michigan Medical School.