Hansen Kim, Schultz Timothy, Crock Carmel, Deakin Anita, Runciman William, Gosbell Andrew
Emergency Department, The Prince Charles Hospital, Brisbane, Queensland, Australia.
School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
Emerg Med Australas. 2016 Oct;28(5):544-50. doi: 10.1111/1742-6723.12620. Epub 2016 Jul 31.
Incident reporting systems are critical to understanding adverse events, in order to create preventative and corrective strategies. There are very few systems dedicated to Emergency Medicine with published results. All EDs in Australia and New Zealand were contacted to encourage the use of an Emergency Medicine - specific online reporting system called the Emergency Medicine Events Register (EMER).
We conducted an analysis of the first 150 incidents entered into EMER. EMER captures Emergency-medicine-specific details including triage score, clinical presentation, outcome, contributing factors, mitigating factors, other specialities involved and patient journey stage. These details were analysed by an expert panel.
Over the first 26 months, 150 incidents were reported into EMER. The most common categories reported, in order, were diagnostic error, procedural complication and investigation errors. Most incidents contained more than one category of error. The most common stage of the patient's journey in which an incident was detected was after discharge from the ED.
A focus on correct diagnosis, procedure performance and investigation interpretation may reduce errors in the ED. The ability to learn from incidents and make system changes to enhance patient safety in healthcare organisations is an inherent part of providing a proactive, quality culture.
事件报告系统对于了解不良事件至关重要,以便制定预防和纠正策略。专门针对急诊医学且有公开结果的系统非常少。我们联系了澳大利亚和新西兰的所有急诊科,鼓励使用一个名为急诊医学事件登记系统(EMER)的特定于急诊医学的在线报告系统。
我们对录入EMER的前150起事件进行了分析。EMER收集了特定于急诊医学的详细信息,包括分诊评分、临床表现、结果、促成因素、缓解因素、涉及的其他专科以及患者就诊阶段。一个专家小组对这些详细信息进行了分析。
在最初的26个月里,有150起事件报告给了EMER。按顺序报告的最常见类别是诊断错误、程序并发症和检查错误。大多数事件包含不止一类错误。发现事件的患者就诊最常见阶段是在从急诊科出院后。
关注正确诊断、程序执行和检查解读可能会减少急诊科的错误。从事件中吸取教训并进行系统变革以提高医疗保健机构患者安全的能力是营造积极主动、高质量文化的内在组成部分。