Near-Miss Events Detected Using the Emergency Department Trigger Tool.
J Patient Saf
; 19(2): 59-66, 2023 03 01.
Article
em En
| MEDLINE
| ID: mdl-36715980
ABSTRACT
OBJECTIVES:
Near misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED).METHODS:
This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED (data from October 1, 2014, to October 31, 2015; 92,859 eligible visits). All patients 18 years and older completing a visit were eligible. We ran the EDTT, a computerized query for triggers on 13 months of ED visit data, reviewing 5582 selected records using a 2-tiered approach. Events were categorized by occurrence (ED vs present on arrival [POA]), severity, omission/commission, and type, using a taxonomy with categories, subcategories, and cross-cutting modifiers.RESULTS:
We identified 1458 ED near misses in 1269 of 5582 records (22.7%) and 80 near misses that were POA. Patient care events represented most ED near misses, including delays in diagnosis, treatment, and failure to monitor, primarily driven by ED boarding and crowding. Medication events were second most common (17%), including 80 medication administration errors. Of 80 POA events, 42% were related to overanticoagulation. We estimate that 19.3% of all ED visits include a near miss.CONCLUSIONS:
Near-miss events are relatively common (22.7% of our sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Near Miss
Tipo de estudo:
Observational_studies
/
Risk_factors_studies
Limite:
Humans
Idioma:
En
Revista:
J Patient Saf
Assunto da revista:
SERVICOS DE SAUDE
Ano de publicação:
2023
Tipo de documento:
Article