Sixty percent of the causes of unintended incidents in the emergency department that could have compromised patient safety are related to human failures, according to a study published in the open access journal BMC Emergency Medicine.
Hospitals and emergency departments are challenging settings with regard to patient safety -- a considerable number of patients suffer from unintended harm caused by healthcare management. Little is known about the causes of unintended events and, thus, these results from Marleen Smits and colleagues from Netherlands Institute for Health Services Research and EMGO Institute for Health and Care Research, may help to target research and interventions to increase patient safety.
The Dutch team studied emergency departments at 10 hospitals in the Netherlands for 8-14 weeks, during which staff were asked to report unintended events, defined as all unintended incidents that could have harmed or did harm a patient.
A total of 522 unintended events were reported, of which more than half of the events had consequences for the patient. A quarter of the reported events related to cooperation between the emergency department and other hospital departments. The team found that most root causes were human (60%), followed by organizational (25%) and technical (11%). Nearly half of the causes were attributable to departments outside the emergency department, such as the laboratory.
Event reports are internationally relevant for healthcare providers and policy makers in the area of emergency medicine. Smits said, "Patient safety in the emergency setting should be improved, especially the collaboration with other hospital departments".
All general hospitals in the Netherlands participate in the safety program "Prevent harm, work safely". They are setting up safety management systems that include incident reporting systems. Moreover, hospitals follow action plans on 10 themes with a high potential for reduction of unintended harm, for example, early detection of a decline in a patient's vital signs, medication verification and prevention of substitutions of patients.
- Marleen Smits, Peter P Groenewegen, Danielle RM Timmermans, Gerrit van der Wal and Cordula Wagner. The nature and causes of unintended events reported at ten emergency departments. BMC Emergency Medicine, 2009; (in press) [link]
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