Chapter 4 Patient Safety in the Emergency Department
Patient safety has become a major concern for clinicians, policy-makers, and health care consumers. This interest began to gain momentum in 1999 with the publication of the Institute of Medicine’s (IOM’s) report To Err is Human: Building a Safer Health System.1 In its report the IOM highlighted the risks of medical care in the United States and provided information about the large numbers of medical error–related deaths per year, as well as other serious adverse events.1 Yet 10 years later consumer groups warn that little progress has been made in the recommended areas of focus for improved safe medication practices, accountability through transparency, monitoring, coordinating and tracking of patient safety issues, and raising the standards of clinical competency.2
The goal of any emergency department is to provide safe, highly effective medical care that optimizes the use of information, people, and resources to achieve the best clinical outcomes. Despite these goals, in 2010, hospital emergency departments were the source of 4.4% of all reported hospital sentinel events and just over half of all reported sentinel event cases of patient death or permanent injury, especially events resulting in delays in treatment.3 Of the 55 cases of delays in treatment, 52 resulted in patient death.3 Commonly cited root causes include staffing, availability of physician specialists, and overcrowding.3 However, these issues are being addressed. Emergency department teams are attacking overcrowding by focusing on social factors with community coalition-building to reduce the need for emergency department visits and to address the needs of a variety of patient populations.4 There is an increased use of pharmacists in the emergency department for the purpose of enhancing medication safety.5 In addition, the Emergency Nurses Association (ENA) has drawn attention to the issue of patient safety by the creation of both a white paper and a position statement regarding patient safety in the emergency department.6,7
What Is Patient Safety?
The National Patient Safety Foundation (NPSF) defines patient safety as “the prevention of health care errors, and the elimination or mitigation of patient injury caused by health care errors.”8 NPSF defines health care error as the “unintended health care outcome caused by a defect in the delivery of care to a patient.”8 These errors may be “ones of commission (doing the wrong thing), omission (not doing the right thing), or execution (doing the right thing incorrectly).”8
“Quality” in health care has been defined as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”9 Patient safety is a subset of quality that provides for “the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care.”8 The Agency for Healthcare Research and Quality (AHRQ) describes patient safety practice as a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures.10
Building a Culture of Safety
Involving the “Front Line”
In order to fully achieve a culture of safety in the emergency department, those who are working at the “front line,” those providing direct care to the patients, must be involved and act as champions for improvement. It is unlikely that this will occur universally until there are major changes to the emergency nursing work environment, specifically by improving the organizational support that nurses need to provide safe care. Studies of work environments have found that nurses may experience greater professional fulfillment when strategies are implemented that promote autonomous practice environments, provide financial incentives, and recognize professional status.11 Particular attention should be paid to safe staffing. Short staffing can increase nursing stress, increase workload, and ultimately may adversely affect patient outcomes.
Leadership Support
One promising intervention for emergency nursing leadership is the implementation of Patient Safety Leadership WalkRounds. WalkRounds have been shown to improve the safety culture of hospitals.12 Leadership WalkRounds consist of a core group of senior leadership staff walking through the hospital on a weekly basis. During these rounds, members of the group ask frontline staff questions about their opinions and perceptions regarding near misses, adverse events, and system issues contributing to these events.
Unit-based patient safety rounds are a modification of these safety rounds. Implementation of safety walk-rounds led by the emergency department director, associate director, nurse director, clerical staff manager, and leaders of the Nurses’ Quality Council in the pediatric emergency department at the Children’s Hospital of Philadelphia resulted in an improvement in safety culture and quality of care.13
Technology
Health information technology (HIT) has been suggested as a possible solution for reducing harm from medical error.14 This may include:
• Electronic error reporting systems
• Computerized prescriber order entry
• Barcode-enabled point of care (BPOC) technology
Teamwork and Communication
A key recommendation of the IOM is that health care organizations should establish “interdisciplinary team training programs for providers that incorporate proven methods of team training.”1
Human factors research, studies of how human beings interact with their environment, has shown that even highly skilled, motivated professionals are vulnerable to error because of human limitations. However, promising research has also shown that clinicians who communicate effectively and back each other up reduce the potential for error, which results in enhanced safety and improved performance.16
It is important for emergency department staff to build teams using validated, evidence-based teamwork and communication programs. One such program, TeamSTEPPS, developed by the Department of Defense and supported by the AHRQ, offers techniques and tools gathered from high-reliability organizations and leveraging evidence from other high-consequence industries such as aviation and nuclear power that enhance communication and other teamwork skills. The TeamSTEPPS model includes four core “pillar” competency areas: leadership, situation monitoring, communication, and mutual support.16 Team leadership sets the tone for a team, directs and coordinates activities, provides feedback through the assessment of team performance, and models team behaviors. Situation monitoring, the ability to scan the environment for threats and hazards, helps to coordinate the team to create a “shared mental model.”17 A mutually supportive environment is one in which it is expected that team members both offer and accept help and provide “back-up behavior” to balance workload. Communication includes standardized methods of exchanging critical and routine information regarding the patient and the health care team and environment.16
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