title: Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process.
abstract: BACKGROUND
  Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives.
  
  
  METHODS
  An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators' experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted.
  
  
  RESULTS
  In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm.
  
  
  CONCLUSIONS
  Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction.
authors.forename: Zach K
authors.initials: ZK
authors.lastname: Jepson
authors.forename: Chad E
authors.initials: CE
authors.lastname: Darling
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Kotkowski
authors.forename: Steven B
authors.initials: SB
authors.lastname: Bird
authors.forename: Michael W
authors.initials: MW
authors.lastname: Arce
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Volturo
authors.affiliation: Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA. mreznek@hotmail.com.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Reznek
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008404:Massachusetts; D019300:Medical Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data*; D018024:Peer Review, Health Care / Q000379:methods / Q000592:standards*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000379:methods / Q000592:standards*; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data
references.citation: Clin Chim Acta. 2009 Jun;404(1):2-5
references.pmid: 19302989
references.citation: Acad Emerg Med. 2007 Aug;14(8):743-9
references.pmid: 17538077
references.citation: Emerg Med J. 2007 Oct;24(10):691-5
references.pmid: 17901266
references.citation: J Grad Med Educ. 2011 Mar;3(1):37-40
references.pmid: 22379521
references.citation: Ann Emerg Med. 1987 Aug;16(8):857-61
references.pmid: 3619164
references.citation: Acad Emerg Med. 2000 Nov;7(11):1204-22
references.pmid: 11073469
references.citation: Lancet. 1999 Apr 3;353(9159):1178-81
references.pmid: 10209997
references.citation: Ann Emerg Med. 2007 Feb;49(2):206-9
references.pmid: 17083994
references.citation: Ann Emerg Med. 2003 Sep;42(3):324-33
references.pmid: 12944883
references.citation: Ann Emerg Med. 2008 Nov;52(5):502-3
references.pmid: 18407373
references.citation: Qual Saf Health Care. 2007 Feb;16(1):40-4
references.pmid: 17301203
references.citation: Ann Emerg Med. 2008 Nov;52(5):497-501
references.pmid: 18353505
references.citation: Eur J Emerg Med. 2013 Feb;20(1):33-8
references.pmid: 22198159
references.citation: Qual Saf Health Care. 2003 Dec;12 Suppl 2:ii64-7
references.pmid: 14645898
references.citation: Clin Orthop Relat Res. 2009 Feb;467(2):352-7
references.pmid: 19048355
references.citation: Intern Emerg Med. 2012 Apr;7(2):173-80
references.pmid: 22009553
references.citation: Ann Emerg Med. 2003 Dec;42(6):815-23
references.pmid: 14634609
references.citation: Ann Emerg Med. 1991 Sep;20(9):1014-6
references.pmid: 1877766
references.citation: Ann Emerg Med. 2012 Nov;60(5):555-563.e20
references.pmid: 23089089