CLINICAL PRACTICE AND PATIENT SAFETY/ORIGINAL RESEARCH
Characteristics of Patient Care Management Problems Identified
in Emergency Department Morbidity and Mortality Investigations
During 15 Years
Karen S. Cosby, MD
Rebecca Roberts, MD
Lisa Palivos, MD
Christopher Ross, MD
Jeffrey Schaider, MD
Scott Sherman, MD
Isam Nasr, MD
Eileen Couture, DO
Moses Lee, MD
Shari Schabowski, MD
Ibrar Ahmad, BS
R. Douglas Scott II, PhD
From the Department of Emergency Medicine, Cook County Hospital, Rush Medical School,
Study objective: 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.
Methods: 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.
Results: 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.
Conclusion: 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. [Ann Emerg Med. 2008;51:251-261.]
0196-0644/$-see front matter
Copyright © 2008 by the American College of Emergency Physicians.
Volume , . : March
Annals of Emergency Medicine 251
SEE EDITORIAL, P. 262.
Several major studies have reported the incidence of medical
error and risks associated with health care.1-6 These studies have
raised awareness of imperfections in care but offer little
understanding of the nature of the work or solutions to improve
safety. Although the focus on patient safety is relatively new,
processes for improvement have existed for decades. We suggest
that cumulative reviews of existing data, available in most health
care organizations, can be used to guide current efforts to
Our study was initially aimed at detecting “medical errors.”
Although the concept of error has been widely disseminated in
the medical literature during the last decade, the term “error”
carries with it connotations of carelessness, implies blame, and
often focuses unduly on humans as the source of harm. As our
understanding of these problems grew, we modified our study
to describe events once labeled errors as “patient care
management problems.” This subtle change is intended to
promote a healthier perspective and constructive analysis. The
term “problem” implies something to be solved and states more
directly our intent to seek strategies and solutions for
Demand for improvement has led to changes throughout
health care, including new safety regulations for health care
organizations, proposed legislation for error reporting and
malpractice reform, and advancements in information
technology applications for medical settings.7-10 Reforms in
medical education have led to restrictions in house staff working
hours, development of curriculums for patient safety, increased
rigor in requirements for lifelong learning for physicians, and
new emphasis on competency standards.11,12 Although we are
anxious to improve, recommended changes should be founded
on a thorough understanding of the types of patient care
management problems that occur in medicine and factors that
may increase risk.
Goals of This Investigation
The objective of this study was to characterize the types of
cases referred to a physician review committee of an urban
emergency department (ED) and identify the phase of work in
which problems were detected and specific factors that affected
quality of patient care. Our long-term goal is to use our existing
morbidity and mortality investigations to guide safety
interventions and to develop valid methods for future study of
patient safety targets. The ED has been described as a high-risk
practice environment, particularly under conditions of
crowding, and serves as a natural setting to study safety in health
MATERIALS AND METHODS
Study Design and Setting
This was a retrospective study to characterize patient care
management problems identified by routine mortality and
morbidity surveillance at an urban public teaching hospital
during the 15-year period spanning 1989 through 2003. The
annual adult ED census during those years ranged from
109,000 to 128,000. All cases referred for emergency physician
review between 1989 and 2003 were eligible. Our institution
has separate reporting mechanisms for pediatric and trauma
care; these populations are not included in our study. Case
referrals came from ED staff, admitting services, consultants, or
quality assurance managers. Two independent emergency
physician reviewers assessed each case by using an existing
framework described previously.15,16 The lead author designed
the data collection form and performed review 1 in every case.
Cases were randomly assigned to one of 8 coinvestigators for
review 2. Whenever possible, reviewers were disqualified from
cases in which they had direct involvement or firsthand
knowledge. The study was exempted from review by our
institutional review board.
Our department actively sought referrals from hospital staff
of cases in which there were concerns about quality of care and
encouraged reports of administrative and system problems, as
well as questions about medical management. This process
began as routine surveillance for morbidity and mortality cases
but became a significant part of the quality process in our
department. Cases underwent an investigation at referral that
included interviews with medical staff involved in each case and
a review of medical records and clinical data. Medical staff were
invited to record details of their cases to explain circumstances
Editor’s Capsule Summary
What is already known on this topic
Morbidity and mortality conferences and other forms of
quality review are commonplace. Their content has not
been well studied.
What question this study addressed
What types of events and what causal and contributing
factors are common in morbidity and mortality reviews?
What this study adds to our knowledge
The diagnostic process was judged the most common
locus of failure in more than 600 cases, spanning 15
years. Despite imperfections in care, more than half the
patients still received some benefit compared with the
likely outcome with no care at all.
How this might change clinical practice
Detailed case reviews provide useful information for
practice improvement but have selection bias in the
choice of cases and biases produced by the retrospective
interpretation of incomplete information.
Patient Care Management ProblemsCosby et al
252 Annals of Emergency Medicine Volume , . : March
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IMAGES IN EMERGENCY MEDICINE
(continued from p. 230)
Emphysematous cystitis. Emphysematous cystitis is a rare, necrotizing infection characterized by gas collection in
the urinary bladder wall and lumen, resulting from gas-producing pathogen infection.1 The risk factors are
diabetes (up to 80%), bladder outlet obstruction, recurrent urinary tract infection, urinary stasis, neurogenic
bladder, immunosuppression, female sex, and being a transplant recipient.2 The mechanism and pathogenesis of
emphysematous cystitis are still unknown. The gas is suggested to be produced by the infected organism by the
fermentation of albumin or glucose in urine. The most common organisms are Escherichia coli,3 Enterobacter
aerogenes, and Klebsiella pneumoniae. Emphysematous cystitis has nonspecific clinical features and is often
misdiagnosed. Clinically, emphysematous cystitis is often diagnosed by the unanticipated imaging findings. Plain
abdominal radiograph usually makes the diagnosis, with high sensitivity (97.4%),4 but abdominal computed
tomography scan was the most sensitive and specific diagnostic tool.5
About 18.8% of emphysematous cystitis cases have complicated courses.4 Emphysematous cystitis demands
prompt diagnosis and intervention,6 including aggressive parenteral antibiotics and even bladder drainage.7
Generally, emphysematous cystitis has favorable prognosis, whereas delays in diagnosis and treatment may
contribute to high mortality rate, which approaches 20%.
A favorable prognosis may be achieved by early recognition of emphysematous cystitis, by clinical and
radiologic assessment, by appropriate antibiotic use, and by timely surgical intervention when indicated.
This patient was administrated empiric antibiotic and promoted surgical drainage. Escherichia coli was isolated
subsequently from both urine and drainage pus cultures. The patient was discharged after a 2-week hospitalization.
1. Quint HJ, Drach GW, Rappaport WD, et al. Emphysematous cystitis: a review of the spectrum of disease. J Urol. 1992;
2. Akalin E, Hyde C, Schmitt G, et al. Emphysematous cystitis and pyelitis in a diabetic renal transplant recipient.
3. Bailey H. Cystitis emphysematosa: 19 cases with intraluminal and interstitial collections of gas. Am J Roentgenol Radium
Ther Nucl Med. 1961;86:850-862.
4. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature.
5. Perlemoine C, Neau D, Ragnaud JM, et al. Emphysematous cystitis. Diabetes Metab. 2004;30:377-379.
6. Quint HJ, Drach GW, Rappaport WD, et al. Emphysematous cystitis: a review of the spectrum of disease. J Urol. 1992;
7. Yasumoto R, Asakawa M, Nishisaka N. Emphysematous cystitis. Br J Urol. 1989;63:644.
Cosby et al Patient Care Management Problems
Volume , . : March
Annals of Emergency Medicine 261
Examples of actions resulting from morbidity and
Uncommon Diagnosis Requiring Complex Evaluations and
The Problem: After observing difficulties in the timely
diagnosis and treatment of aortic dissections, we reviewed a
series of cases of aortic dissections from our morbidity and
mortality database and identified key problem areas. The
diagnosis was observed to be difficult, often overlapping more
common chest pain entities. The evaluation for dissection could
involve a variety of approaches (echocardiography, computed
tomography, or angiography) and involved multiple consultants
(chest surgeons, cardiologists, vascular surgeons, intensivists,
and interventional radiologists). Because of the variation in
practice, there was often conflict between specialists and services
about the optimal testing and management of these cases; care
was often delayed by conflict and indecision.
Actions Taken: After review of a series of problematic cases,
the ED staff convened a multidisciplinary conference with all
the involved specialties, eventually developing a standard
approach agreed on by all disciplines. Once the policy was
developed, hospital staff worked to ensure that services were
available to follow the protocol. The result was a much more
simplified and direct approach to caring for similar cases.
Cases With Evolving Standards of Care and Controversy
About Optimal Management: Ectopic Pregnancy
The Problem: Multiple problems were observed in the
timely diagnosis of ectopic pregnancy and in management of
patients with first trimester bleeding. Because of evolving
standards in the care of patients with first trimester pregnancy,
the ED staff experienced conflict and inconsistent standards
within their own group, as well as consultants. In the process,
the diagnosis of several ectopic pregnancies was delayed.
Actions Taken: The ED organized a literature review and
grand rounds conference on ectopic pregnancy, developed a
treatment protocol for first trimester pregnancy, and then met
with a working group with obstetrics to standardize criteria for
consultation, admission, and follow-up. Meanwhile, the ED
improved its proficiency in bedside ultrasonography and began
more liberal screening of all first trimester pregnancy bleeding.
Dealing With a Local Infectious Disease Threat:
The Problem: A resurgence of tuberculosis in our city led to
an increase in number of patients with active tuberculosis in our
ED. There were a limited number of isolation beds available
within the hospital, and medical staff had too few beds to isolate
all potential cases. A number of patients admitted to general
medical wards were found to have active tuberculosis; at the
same time, there was an increase in the number of house staff
who converted to positive tuberculin skin tests.
The Action: Cases with positive tuberculosis culture results
were identified and their ED records tracked. The ED convened
a multidisciplinary conference with the Infectious Disease and
Radiology Departments to review the cases. Ultimately, we
found that many active cases of tuberculosis could not be
predicted according to clinical and radiographic criteria.
Eventually, the medical staff obtained additional isolation
rooms in the ED and in the hospital, applied new screening at
triage to prioritize chest radiographs in patients with respiratory
symptoms, prioritized movement of patients with suspected
cases from triage to isolation beds in the ED, and successfully
argued for increased resources to handle the challenge.
261.e1 Annals of Emergency MedicineVolume , . : March