Characteristics of Patient Care Management Problems Identified in Emergency Department Morbidity and Mortality Investigations During 15 Years

Department of Emergency Medicine, Cook County Hospital, Rush Medical School, Chicago, IL 60612, USA.
Annals of emergency medicine (Impact Factor: 4.68). 04/2008; 51(3):251-61, 261.e1. DOI: 10.1016/j.annemergmed.2007.06.483
Source: PubMed


We describe cases referred for physician review because of concern about quality of patient care and identify factors that contributed to patient care management problems.
We performed a retrospective review of 636 cases investigated by an emergency department physician review committee at an urban public teaching hospital over a 15-year period. At referral, cases were initially investigated and analyzed, and specific patient care management problems were noted. Two independent physicians subsequently classified problems into 1 or more of 4 major categories according to the phase of work in which each occurred (diagnosis, treatment, disposition, and public health) and identified contributing factors that likely affected outcome (patient factors, triage, clinical tasks, teamwork, and system). Primary outcome measures were death and disability. Secondary outcome measures included specific life-threatening events and adverse events. Patient outcomes were compared with the expected outcome with ideal care and the likely outcome of no care.
Physician reviewers identified multiple problems and contributing factors in the majority of cases (92%). The diagnostic process was the leading phase of work in which problems were observed (71%). Three leading contributing factors were identified: clinical tasks (99%), patient factors (61%), and teamwork (61%). Despite imperfections in care, half of all patients received some benefit from their medical care compared with the likely outcome with no care.
These reviews suggest that physicians would be especially interested in strategies to improve the diagnostic process and clinical tasks, address patient factors, and develop more effective medical teams. Our investigation allowed us to demonstrate the practical application of a framework for case analysis. We discuss the limitations of retrospective cases analyses and recommend future directions in safety research.

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    • "Kendall Hall and team found during a year long active surveillance of their emergency department that the largest proportion of errors were due to medication, therapeutic and diagnostic delays, followed by complications . These are also known risk factors to emergency department patients (Newar, et al., 2005; Cosby, et al., 2008). The patient often enters emergency department care without a known medical history, so extensive coordination across multiple organizational sections must be carried out quickly. "
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    ABSTRACT: The scope of ambulatory care practice in the United States has steadily increased over the past several decades. Ambulatory care has always involved a highly distributed collection of organizations, whose safety and quality substantially varies. The US Insti-tute of Medicine has in repeated publications impressed the importance of using risk in-formed approaches, which are used in industry, to eliminate, replace, isolate, engineer or administratively contain potential and actual risk and harm to patient care. Combined with sensemaking approaches, this model and supporting assortment of tools provide a robust capability to substantially improve the quality of US ambulatory care. In 2007, the US Agency for Healthcare Research and Quality funded over a dozen such initiatives as part of its Risk Informed Intervention program. This paper provides an important over-view of risk informed approaches and how these tools are being used to facilitate quality improvement implementations across the US.
    17th World Congress on Ergonomics; 08/2009
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  • Annals of emergency medicine 04/2008; 51(3):262-4. DOI:10.1016/j.annemergmed.2007.08.022 · 4.68 Impact Factor
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