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.
More articles on patient safety:
7 in 10 safety leaders lack data to change patient harms, survey finds
Chuck Lauer: EHRs seem like more of a problem than a solution
3 tips for picking the right endoscope instrument reprocessing cleaner
At the Becker's 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health, taking place September 14–17 in Chicago, healthcare executives and digital leaders from across the country will come together to explore how AI, interoperability, cybersecurity, and revenue cycle innovation are transforming care delivery, strengthening financial performance, and driving the next era of digital health. Apply for complimentary registration now.