Patient safety incidents in the ER: Study pinpoints major causes

Systems failures are nearly twice as likely as practitioner errors to contribute to patient safety incidents in emergency departments, according to a study published in BMC Emergency Medicine.

Researchers conducted an observational study at a large tertiary-care ED over a two-year period. During the study, 152 PSIs were identified. Each case was reviewed for six types of systems failures — triage, ED teamwork, hospital teamwork, ED work environment, hospital work environment and boarded patient — and five practitioner-based errors — major cognitive error, cognitive error, missed radiographic finding, policy deviation or procedural error.

In total, 188 systems failures and 96 practitioner-based errors contributed to the 152 PSIs. Of the 152 total cases, 12 led to patient harm, and systems failures were identified in 11 of those 12 cases.

"To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction," the study authors concluded.

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