Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J 2016;33:245-252
This new study shows the potential of voluntary reports to help identify and learn from errors.
First, the study itself was part of a broader culture of safety that every emergency department could adapt to identify and learn from errors: “The voluntary non-punitive incident-reporting system was implemented after a campaign to encourage physicians to 1) acknowledge the ED as an error-prone environment; 2) report near misses, adverse events and medical errors and 3) increase collaboration with ED staff and other medical disciplines to establish a culture of safety.”
Incidents were identified in four ways: “1) On a return visit to the ED, the patient is evaluated by the same physician who discovers an error and self-reports an incident. 2) A second care team involved in a return ED visit or a shift change discovers a possible error and reports the incident. 3) The inpatient care team postadmission identifies an error made by the ED and reports it to the ED medical director who would log the incident in the reporting system. 4) An error is discovered on a routine review conducted by our ED on all return visits to the ED within 72 hours or death within 24h of admission. These incidents are also reported to the ED medical director who enters them into the reporting system.” Each incident was emailed to the physician named, who completed a form that was reviewed by the Quality Assurance team that classified them according to type of error (procedural error, diagnostic error, inappropriate disposition, inappropriate or delayed therapy, inappropriate testing or other) and degree of patient harm (minor, moderate or major)
Results: from 2009 to 2013 over 509 incidents were reported, of which a sixth resulted in major harm and a third in minor harm. Three quarters had more than one contributing factor
- 300 non-diagnostic related
- 209 diagnostic related
- 317 cognitive factors: faulty information verification, faulty information procesesing, faulty data gathering, faulty knowledge
- 192 system-related: inefficient process, high workload, inadequate handoff, insufficient resources, non-handoff communication, poor equipment
- 106 non-remedial factors: atypical presentation, limited historian, complicated history, language barrier, rare, psychiatric, non-adherence
Diagnostic errors that resulted in at least 5 cases, in decreasing order of frequency were: sepsis, ACS, fractures, vascular (AAA, dissections), CVA, dysrhythmia, non-septic shock, hypoglycemia, ectopic, electrolyte abnormality, pericardial effusion, pneumonia, PE.
The study not only highlighted the types of errors in the emergency department, but through the process helped develop error prevention strategies, including: standardized orders, standardized sign-out, treatament protocols, skills campaigns on vulnerable areas (eg ECG, ultrasound, vents), and a quarterly newsletter to foster an open communication of error and to improve the culture of safety.