Using Medical Emergency Teams to detect preventable adverse events.
BACKGROUND
Medical Emergency Teams (METs), also known as Rapid Response Teams, are recommended as a patient safety measure. A potential benefit of implementing an MET is the capacity to systematically assess preventable adverse events, which are defined as poor outcomes caused by errors or system design flaws. We describe how we used MET calls to systematically identify preventable adverse events in an academic tertiary care hospital, and describe our surveillance results.


METHODS
For four weeks we collected standard information on consecutive MET calls. Within a week of the MET call, a multi-disciplinary team reviewed the information and rated the cause of the outcome using a previously developed rating scale. We classified the type and severity of the preventable adverse event.


RESULTS
We captured information on all 65 MET calls occurring during the study period. Of these, 16 (24%, 95% confidence interval [CI] 16%-36%) were felt to be preventable adverse events. The most common cause of the preventable adverse events was error in providing appropriate therapy despite an accurate diagnosis. One service accounted for a disproportionate number of preventable adverse events (n = 5, [31%, 95% CI 14%-56%]).


CONCLUSIONS
Our method of reviewing MET calls was easy to implement and yielded important results. Hospitals maintaining an MET can use our method as a preventable adverse event detection system at little additional cost.
Iyengar
Akshai
A
Department of Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada. aiyengar@ottawahospital.on.ca
Baxter
Alan
A
Forster
Alan J
AJ
D000368:Aged; D000369:Aged, 80 and over; D057209:Hospital Rapid Response Team; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D009864:Ontario