The effect of visitation restrictions on ED error.

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients-actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

The effect of increasing emergency department observation volumes on downstream admission rates.

Rising length of stay and inpatient boarding in emergency departments have directly affected patient satisfaction and nearly all provider-to-patient care metrics. Prior studies suggest that ED observation has significant clinical and financial benefits including decreasing hospitalization and length of stay. ED observation is one method long employed to shorten ED length of stay and to free up inpatient beds, yet many patients continue to be admitted to the hospital with an average hospital length of stay of only one day. The objectives of this study were to evaluate whether vigorous tracking and provider reviews of one day hospital admits affected the utilization of ED observation and whether this correlated with significant change in rates of admission from observation status. Between September 2020 and May 2021, in a tertiary care hospital with an annual ED volume of 55,0000, chart reviews of 24-h inpatient discharges were initiated by two senior EM faculty to determine perceived suitability for ED observation. Non-punitive email reviews were then initiated with ED attending providers in order to encourage evaluation of whether these patients would have benefitted from being placed into observation. We then analyzed ED observation patient volumes and subsequent admission rates to the hospital from ED observation and compared these numbers to baseline ED observation volume and admission rates between September 2018 and May 2019. A total of 1448 reviews were conducted on 24-h discharges which correlated with an increase in utilization of ED observation from 11.77% (95% CI [11.62, 12.31]) of total ED volume in our control period to 14.21% (95% CI [13.84, 14.58]) during the study period. We found that the overall admission rate from ED observation increased from 20.12% (95% CI [18.97, 21.26]) baseline to 23.80% (95% CI [22.60, 25.00]) during the same time periods. Our data suggest that increasing the total number of patients placed into observation by 21% correlated with a relative increase in admission rates from ED observation by 18%. This would suggest that our efforts to potentially include more patients into our observation program led to a significant increase in subsequent admission rates. There is likely a balance that must be struck between under- and over-utilization of ED observation, and expanding ED observation may be an effective solution to hospital boarding and ED overcrowding.

The Value of Using a Quality Assurance Follow-Up Team to Address Incidental Findings After Emergency Department or Urgent Care Discharge: A Cost Analysis.

BACKGROUND: Incidental finding (IF) follow-up is of critical importance for patient safety and is a source of malpractice risk. Laboratory, imaging, or other types of IFs are often uncovered incidentally and are missed, not addressed, or only result after hospital discharge. Despite a growing IF notification literature, a need remains to study cost-effective non-electronic health record (EHR)-specific solutions that can be used across different types of IFs and EHRs. OBJECTIVE: The objective of this study was to evaluate the utility and cost-effectiveness of an EHR-independent emergency medicine-based quality assurance (QA) follow-up program in which an experienced nurse reviewed laboratory and imaging studies and ensured appropriate follow-up of results. METHODS: A QA nurse reviewed preceding-day abnormal studies from a tertiary care hospital, a community hospital, and an urgent care center. Laboratory values outside preset parameters or radiology over-reads resulting in clinically actionable changes triggered contact with an on-call emergency physician to determine an appropriate intervention and its implementation. RESULTS: Of 104,125 visits with 1,351,212 laboratory studies and 95,000 imaging studies, 6530 visits had IFs, including 2659 laboratory and 4004 imaging results. The most common intervention was contacting a primary care physician (5783 cases [88.6%]). Twenty-one cases resulted in a patient returning to the ED, at an average cost of $28,000 per potential life-/limb-saving intervention. CONCLUSIONS: Although abnormalities in laboratory results and imaging are often incidental to patient care, a dedicated emergency department QA follow-up program resulted in the identification and communication of numerous laboratory and imaging abnormalities and may result in changes to patients' subsequent clinical course, potentially increasing patient safety.

Can Asking Emergency Physicians Whether or Not They Would Have Done Something Differently (WYHDSD) be a Useful Screening Tool to Identify Emergency Department Error?

BACKGROUND: Error in emergency medicine remains common and difficult to identify. OBJECTIVE: To evaluate if questioning emergency physician reviewers as to whether or not they would have done something differently (Would you have done something differently? [WYHDSD]) can be a useful marker to identify error. METHODS: Prospective data were collected on all patients presenting to an academic emergency department (ED) between 2017 and 2021. All cases who met the following criteria were identified: 1) returned to ED within 72 h and admitted; 2) transferred to intensive care unit from floor within 24 h of admission; 3) expired within 24 h of arrival; or 4) patient or provider complaint. Cases were randomly assigned to emergency physicians and reviewed using an electronic tool to assess for error and adverse events. Reviewers were then mandated to answer WYHDSD in the management of the case. RESULTS: During the study period, 6672 cases were reviewed. Of the 5857 cases where reviewers would not have done something differently, 5847 cases were found to have no error. The question WYHDSD had a sensitivity of 97.4% in predicting error and a negative predictive value of 99.8%. CONCLUSION: There was a significantly higher rate of near misses, adverse events, and errors attributable to an adverse event in cases where the reviewer would have done something differently (WHDSD) compared with cases where they would not. Therefore, asking reviewers if they WHDSD could potentially be used as a marker to identify error and improve patient care in the ED.

The Association between Emergency Department Length of Stay and In-Hospital Mortality in Older Patients Using Machine Learning: An Observational Cohort Study.

The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age ≥60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and ≥90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and ≥90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and ≥90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS ≤1 h (9.96%) vs. higher EDLOS 7 h

The data and the reality: urine cultures and emergency medicine physicians.

BACKGROUND AND OBJECTIVES: The IDSA has published guidelines for the treatment of urinary tract infections, recommending limiting treatment to symptomatic patients and pregnant females. Our objective is to elucidate current practice patterns among emergency physicians (EPs) in treating positive urine cultures in various clinical situations. METHODS: This study employed a cross-sectional design utilizing a questionnaire addressing nine common scenarios encountered by EPs in the follow-up of a positive urine culture. The questionnaire was conducted using RedCap and distributed via email to current and former physicians and residents across our hospital network. Demographic information included years of training and practice setting. For each of nine clinical scenarios, Physicians were asked if they would treat with antibiotics. Results were then analyzed by tabulating percentage of responses and 95% confidence intervals. RESULTS: Of 120 respondents, 40.8% worked in academic centers with emergency medicine residencies, 37.5% in large community hospitals, and 20.67% in small community hospitals. Responses came from 14 residents, 33 attendings < 5 years out of training, 23 attendings 5-9 years out of training, 37 attendings 10-20 years out of training, and 13 attendings > 20 beyond training. Asymptomatic young women were treated by 34.2% (95% CI 25.91-43.46%) while asymptomatic elderly women were treated by 50% (95% CI 40.79-59.21%) of EPs. All EPs (95% CI 96.13-100%) chose to treat a symptomatic male and 99.2% (95% CI 94.77-99.96%) chose to treat an asymptomatic pregnant female. Elderly females after a fall were treated by 63.3% (95% CI 54-71.8%) of EPs while elderly males with confusion and a fall were treated by 96.7% (95% CI 91.18-98.93%). Asymptomatic males with a chronic Foley catheter were treated by 28.2% (95% CI 20.67-37.4%) of EPs and 46.7% (95%CI 37.59-55.97%) would treat an asymptomatic middle-aged female with diabetes. Finally, 92.5% (95% CI 85.85-96.3%) of EPs chose to treat an asymptomatic kidney transplant patient. CONCLUSION: EPs in varied training stages and practice settings have significant practice variation in the treatment of positive urine cultures, particularly in the geriatric population, often prescribing antibiotics to patients where clear, specific and data-driven IDSA guidelines suggest treatment is unnecessary and potentially harmful.

Electronic health record-based patient tracking by emergency medicine physicians.

Objectives: Emergency medicine (EM) physicians commonly track the progress of former patients to learn about their clinical outcome. While some studies have described the behavior, little is known about the specific information sought during tracking. The objective of this study was to determine how often EM physicians track patients and the motivations, strategies, and barriers to tracking. Methods: In June 2019 we surveyed EM physicians practicing at six hospitals. We defined patient tracking as viewing the chart of a patient who was no longer under the physician's care or contacting the patient or the patient's subsequent providers to learn about the patient's progress. The survey asked respondents how often they track patients, by what mechanisms, and for what reasons. The survey also asked what information physicians sought when tracking and what barriers to tracking exist. Results: Of the 156 EM physicians invited to respond, 111 completed the survey (72% response rate). Of those, 109 (98%) reported tracking their patients, and residents reported tracking a higher percentage of patients than attendings. Reasons for tracking included an unusual or complex case (98%), uncertain diagnosis (89%), and concern about a potential error (48%). Most respondents (86%) said that knowledge gained from patient tracking changed their subsequent practice patterns, and almost all respondents (98%) strongly agreed or agreed that tracking helps physicians avoid future mistakes. The most commonly sought information types during tracking were the hospital discharge summary or emergency department note from the index visit, test results since the index visit, and new diagnoses added since the index visit. Physicians cited time limitations and difficulty accessing information as the leading barriers to tracking. Conclusions: Patient tracking is nearly ubiquitous among surveyed EM physicians, who find it valuable for learning and patient safety.

Assessing resident and attending error and adverse events in the emergency department.

BACKGROUND: There is a paucity of data looking at resident error or contrasting errors and adverse events among residents and attendings. This type of data could be vital in developing and enhancing educational curricula OBJECTIVES: Using an integrated, readily accessible electronic error reporting system the objective of this study is to compare the frequency and types of error and adverse events attributed to emergency medicine residents with those attributed to emergency medicine attendings. METHODS: Individual events were classified into errors and/or adverse events, and were attributed to one of three groups-residents only, attendings only, or both (if the event had both resident and attending involvement). Error and adverse events were also classified into five different categories of events-systems, documentation, diagnostic, procedural and treatment. The proportion of error events were compared between the residents only and the attendings only group using a one-sample test of proportions. Categorical variables were compared using Fisher's exact test. RESULTS: Of a total of 115 observed events over the 11-month data collection period, 96 (83.4%) were errors. A majority of these errors, 40 (41.7%), were attributed to both residents and attendings, 20 (20.8%) were attributed to residents only, and 36 (37.5%) were attributed to attendings only. Of the 19 adverse events, 14 (73.7%) were attributed to both residents and attendings, and 5 (26.3%) adverse events were attributed to attendings only. No adverse events were attributed solely to residents (Table 1). Excluding events attributed to both residents and attendings, there was a significant difference between the proportion of errors attributed to attendings only (64.3%, CI: 50.6, 76.0), and residents only (35.7%, CI: 24.0, 49.0), p = 0.03. (Table 2). There was no significant difference between the residents only and the attendings only group in the distribution of errors and adverse events (Fisher's exact, p = 0.162). (Table 2). There was no statistically significant difference between the two groups in errors that did not result in adverse events and the rate of errors proceeding to adverse events (Fisher's exact, p = 0.15). (Table 3). There was no statistically significant difference between the two groups in the distribution of the types of errors and adverse events (Fisher's exact, p = 0.09). Treatment related errors were the most common error types, for both the attending and the resident groups. CONCLUSIONS: Resident error, somewhat expectedly, is most commonly related to treatment interventions, and rarely is due to an individual resident mistake. Resident error instead seems to reflect concomitant error on the part of the attending. Error, in general as well as adverse events, are more likely to be attributed to an attending alone rather than to a resident.

Analysis of Risk Factors for Patient Safety Events Occurring in the Emergency Department.

OBJECTIVE: The aim of the study was to describe and analyze the risk factors associated with patient safety events (PSEs), defined as adverse events (AEs), preventable AEs (PAEs), and near-miss events (NMEs), in the emergency department (ED). METHODS: It was a retrospective cohort study using ED patients' data retrieved from January 2010 to December 2016. Quality assurance issues (QAIs) used as triggers included the following: issues during procedural sedation, death within 24 hours of admission, patients' and physicians' complaints, returns to the ED within 72 hours, and transfers to an intensive care unit within 24 hours. RESULTS: Of 383,586 ED visits, 6519 (1.7%) QAIs were reported with a PSEs incidence of 6.1%. Among the 397 PSEs, 258 were AEs including 82 PAEs, and 139 NMEs. During the 7-year period, we observed a fourfold increase in NMEs, and despite a decrease in the rate of AEs with the highest (3.1%) and lowest (0.8%) incidence in 2011 and 2016, respectively, the incidence of PAEs events remained relatively constant. Unadjusted analysis showed that ED waiting time, boarding time, ED length of stay (LOS), ED disposition, as well as diagnostic and QAIs were significantly related to PSEs (P < 0.05). Multivariable analysis showed that the type of QAIs and diagnostic were associated with PSEs (P < 0.001). Type of QAIs was a risk factor for AEs and PAEs occurrence and factors involved in NMEs were type of QAIs (P = 0.02) and ED LOS (P < 0.001). "The odds of a PSE occurring increased by 0.2% for each additional minute increase in the ED waiting time, by 5.2% for each additional boarding hour, and by 4.5% for each ED LOS hour." CONCLUSIONS: This study showed several potential risk factors for PSEs, especially ED LOS, type of QAIs, and diagnostic. Systematic interventions might have more impact on risk of PSE.

Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments: A Systematic Review.

OBJECTIVES: This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings. METHODS: We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resources Information Centre for peer-reviewed journal articles published from January 1, 1988, to June 8, 2018, that assessed teamwork and communication interventions focusing on how they influence patient safety in the ED. One additional search update was performed in July 2019. RESULTS: Sixteen studies were included from 8700 screened publications. The studies' design, interventions, and evaluation methods varied widely. The most impactful ED training interventions were End-of-Course Critique, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and crisis resource management (CRM)-based training. Crisis resource management and TeamSTEPPS CRM-based training curriculum were used in most of the studies. Multiple tools, including the Kirkpatrick evaluation model, the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, the TeamSTEPPS Teamwork Attitudes Questionnaire, the Safety Attitudes Questionnaire, and the Communication and Teamwork Skills Assessment, were used to assess the impact of such interventions. Improvements in one of the domains of safety culture and related domains were found in all studies. Four empirical studies established improvements in patient health outcomes that occurred after simulation CRM training (Kirkpatrick 4), but there was no effect on mortality. CONCLUSIONS: Overall, teamwork and communication training interventions improve the safety culture in ED settings and may positively affect patient outcome. The implementation of safety culture programs may be considered to reduce incidence of medical errors and adverse events.

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis.

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

A Tale of Two Cities: Applying the Boston Syncope Criteria to Jerusalem.

BACKGROUND: Syncope is a common reason for emergency department (ED) visits; however, the decision to admit or discharge patients after a syncopal episode remains challenging for emergency physicians. Decision rules such as the Boston Syncope Criteria have been developed in an attempt to aid clinicians in identifying high-risk patients as well as those who can be safely discharged, but applying these rules to different populations remains unclear. OBJECTIVES: To determine whether the Boston Syncope Criteria are valid for emergency department patients in Israel. METHODS: This retrospective cohort convenience sample included patients who visited a tertiary care hospital in Jerusalem from August 2018 to July 2019 with a primary diagnosis of syncope. Thirty-day follow-up was performed using a national health system database. The Boston Syncope Criteria were retrospectively applied to each patient to determine whether they were at high risk for an adverse outcome or critical intervention, versus low risk and could be discharged. RESULTS: A total of 198 patients fulfilled the inclusion criteria and completed follow-up. Of these, 21 patients had either an adverse outcome or critical intervention. The rule detected 20/21 with a sensitivity of 95%, a specificity of 66%, and a negative predictive value of 99. CONCLUSIONS: The Boston Syncope Criteria may be useful for physicians in other locations throughout the world to discharge low-risk syncope patients as well as identify those at risk of complications.

Errors in Decisionmaking in Emergency Medicine: The Case of the Landscaper's Back and Root Cause Analysis.

Root cause analysis is often suggested as a means of conducting quality assurance, but few physicians are familiar with the actual process. We describe a detailed approach to conducting root cause analysis, with an illustrative case to explain the technique. By studying how root cause analysis is applied to the case of a missed epidural abscess, the reader will see how the process reveals systems improvements that reduce the risk that such a miss will happen again. Following this process will be helpful in using root cause analysis to fix not just individuals' issues but also but systemwide quality assurance issues to improve patient care.

The utility of emergency department physical therapy and case management consultation in reducing hospital admissions.

BACKGROUND: A significant number of patients who present to the emergency department (ED) following a fall or with other injuries require evaluation by a physical therapist. Traditionally, once emergent conditions are excluded in the ED, these patients are admitted to the hospital for evaluation by a physical therapist to determine whether they should be transferred to a sub-acute rehabilitation facility, discharged, require services at home, or require further inpatient care. Case management is typically used in conjunction with a physical therapist to determine eligibility for recommended services and to aid in placement. OBJECTIVE: To evaluate the benefit of using ED-based physical therapist and case management services in lieu of routine hospital admission. METHODS: Retrospective, observational study of consecutive patients presenting to an urban, tertiary care academic medical center ED between December 1, 2017, and November 30, 2018, who had a physical therapist consult placed in the ED. We additionally evaluated which of these patients were placed into ED observation for physical therapist consultation, how many required case management, and ED disposition: discharged home from the ED or ED observation with or without services, placed in a rehabilitation facility, or admitted to the hospital. RESULTS: During the 12-month study period, 1296 patients (2.4% of the total seen in the ED) were assessed by a physical therapist. The mean age was 75.5 ± 15.2 and 832 (64.2%) were female. Case management was involved in 91.8% of these cases. The final patient disposition was as follows: admission 24.3% (95% CI = 22.1-26.7%), home discharge with or without services 47.8% (95% CI = 45.1-50.5%), rehabilitation (rehab) setting 27.9% (95% CI = 25.6%-30.4). The median (interquartile range) time in observation was 13.1 (6.0-20.3), 9.9 (1.8-15.8), and 18.4 (14.1-24.8) hours for patients admitted, discharged home, or sent to rehabilitation (P < 0.001). Among the 979 patients discharged home or sent to rehabilitation, 17 (1.7%) returned to the ED within 72 hours and were ultimately admitted. CONCLUSION: Given that the standard of care would otherwise be an admission to the hospital for 1 day or more for all patients requiring physical therapist consultation, an ED-based physical therapy and case management system serves as a viable method to substantially decrease hospital admissions and potentially reduce resource use, length of hospital stay, and cost both to patients and the health care system.

Using a rule-based system to define error in the emergency department.

INTRODUCTION: The evaluation of peer-reviewed cases for error is key to quality assurance (QA) in emergency medicine, but defining error to ensure reviewer agreement and reproducibility remains elusive. The objective of this study was to create a consensus-based set of rules to systematically identify medical errors. METHODS: This is a prospective, observational study of all cases presented for peer review at an urban, tertiary care, academic medical center emergency department (ED) quality assurance (QA) committee between October 13, 2015, and September 14, 2016. Our hospital uses an electronic system enabling staff to self-identify QA issues for subsequent review. In addition, physician or patient complaints, 72-hour returns with admission, death within 24 hours, floor transfers to ICU < 24 hours, and morbidity and mortality conference cases are automatic triggers for review. Trained reviewers not involved in the patient's care use a structured 8-point Likert scale to assess for error and preventable or non-preventable adverse events. Cases where reviewers perceived a need for additional treatment, or that caused patient harm, are referred to a 20-member committee of emergency department leadership, attendings, residents, and nurses for consensus review. For this study, "rules" were proposed by the reviewers identifying the error and validated by consensus during each meeting. The committee then decided if a rule had been broken (error) or not broken (judgment call). If an error could not be phrased in terms of a rule broken, then it would not be considered an error. The rules were then evaluated by 2 reviewers and organized by theme into categories to determine common errors in emergency medicine. RESULTS: We identified 108 episodes of rules broken in 103 cases within a database of 920 QA reviewed cases. In cases where a rule was broken and therefore an error was scored, the following 5 major themes emerged: (1) not acquiring necessary information (eg, not completing a relevant physical exam), N = 33 (31%); (2) not acting on data that were acquired (eg, abnormal vital signs or labs), N = 25 (23%); (3) knowledge gaps by clinicians (eg, not knowing to reduce a hernia), N = 16 (15%); (4) communication gaps (eg, discharge instructions), N = 17 (16%); and (5) systems issues (eg, improper patient registration), N = 17 (16%). CONCLUSION: The development of consensus-based rules may result in a more standardized and practical definition of error in emergency medicine to be used as a QA tool and a basis for research. The most common type of rule broken was not acquiring necessary information. A rule-based definition of medical error in emergency medicine may identify key areas for risk reduction strategies, help standardize medical QA, and improve patient care and physician education.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events.

OBJECTIVE: Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. METHODS: We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. RESULTS: EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%-7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%-2.9%). CONCLUSION: A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Management pathway for emergency department patients in the setting of the opioid epidemic and emergency department overcrowding.

OBJECTIVE: The United States is currently in the midst of a major opioid addiction epidemic, of which the primary drivers are a sharp increase in prescription opioid pain medications, their misuse, and the inordinate illicit use of opioids. Declared a national health emergency, the opioid crisis puts enormous pressure on various systems, including increasing overcrowding in emergency departments (EDs) and forced changes in prescribing practices. We are piloting a newlydeveloped ED opiate pathway to streamline ED care for patients who frequently present at the ED for chronic pain management or other recurrent pain-causing medical problems. METHODS: Patients at risk of possible opioid addiction are identified and their records are reviewed. If there is no narcotics agreement in place, the ED care team contacts the primary care physician and any other service providers involved in the patient's care to create a comprehensive pain management program. RESULTS: Our pathway is simple and geared toward streamlining and improving care for patients with opioid addiction and misuse. We looked at seven patients in this pilot study with mixed results regarding decreasing future ED visits. CONCLUSION: This strategy may both limit opioid usage and abuse as well as limit ED visits and overcrowding by streamlining ED care for patients who frequently present for chronic pain management or other recurrent medical problems.

The Ethics of Error in Medicine.

The practice of medicine forces medical practitioners to make difficult and challenging choices on a daily basis. On the one hand we are obligated to cure with every resource available, while on the other hand we put the patient at risk because our treatments are flawed. To understand the ethics of error in medicine, its moral value, and the effects, error must first be defined. However, definition of error remains elusive, and its incidence has been extraordinarily difficult to quantify. Yet, a health care system that acknowledges error as a consequence of normative ethical practice must create systems to minimize error. Error reduction, in turn, should attempt to decrease patient harm and improve the entire health care system. We discuss a number of ethical and moral considerations that arise from practicing medicine despite anticipated error.