title: Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Emergency Medicine, Cook County Hospital, Rush Medical School, Chicago, IL 60612, USA. kcosby@ccbh.org
authors.forename: Karen S
authors.initials: KS
authors.lastname: Cosby
authors.forename: Rebecca
authors.initials: R
authors.lastname: Roberts
authors.forename: Lisa
authors.initials: L
authors.lastname: Palivos
authors.forename: Christopher
authors.initials: C
authors.lastname: Ross
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Schaider
authors.forename: Scott
authors.initials: S
authors.lastname: Sherman
authors.forename: Isam
authors.initials: I
authors.lastname: Nasr
authors.forename: Eileen
authors.initials: E
authors.lastname: Couture
authors.forename: Moses
authors.initials: M
authors.lastname: Lee
authors.forename: Shari
authors.initials: S
authors.lastname: Schabowski
authors.forename: Ibrar
authors.initials: I
authors.lastname: Ahmad
authors.forename: R Douglas
authors.initials: RD
authors.lastname: Scott
mesh_terms: D003933:Diagnosis; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D008485:Medical Audit; D019300:Medical Errors / Q000145:classification / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D010346:Patient Care Management / Q000592:standards / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012189:Retrospective Studies