Measuring patient safety in the emergency department.

As a safety net for the health care system, quality and safety performance in emergency medicine (EM) is important for policy makers, insurers, researchers, health care providers, and patients. Developing performance indicators that are relevant, valid, feasible, and easy to measure has proven difficult. To monitor progress, patient safety should be measured objectively. Although conceptual frameworks and error taxonomies have been proposed, a practical scorecard for measuring patient safety over time in EM has been lacking. This article proposes a framework that measures safety through 4 major domains: (1) how often patients are harmed, (2) how often appropriate interventions are delivered, (3) how well errors in the system are identified and corrected, and (4) emergency department (ED) safety culture. Examples of specific measures for each of these domains are provided, but the EM community should reach consensus on what measures are important for the ED environment and patients.

The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers.

BACKGROUND: Every year, patients leave the Emergency Department against medical advice (AMA) and before an adequate evaluation can be performed. It is well known that many of these patients are at risk of subsequent complications. OBJECTIVE: The goal of this article is to explain the potential legal protections that may be created from a proper AMA discharge. DISCUSSION: In this article, the authors review the steps that need to be taken when performing an AMA discharge, including an assessment of capacity, proper documentation, and adequate disclosure. The authors then review the potential legal protections that can result from a properly documented and performed discharge. Among these protections are: proof that the provider's duty to the patient ended with discharge and that the patient assumed the risk of a subsequent complication. CONCLUSION: The authors conclude that a properly executed discharge can provide significant legal protection from liability risks.

ICU triage: the potential legal liability of withdrawing ICU care during a catastrophic event.

In the event of a catastrophic disaster, healthcare resources may be completely overwhelmed. To address this, the federal Agency for Healthcare Research and Quality has recommended using "crisis standards of care"during such an event. These standards would recommend allocating scarce medical resources to do the greatest good for the greatest number of patients. In a dire catastrophic event, such standards may include the allocation of intensive care unit (ICU) resources to maximize patient survival. Triage protocols that seek to efficiently allocate ICU resources during a disaster have been reviewed by the Institute of Medicine. Such protocols suggest the exclusion of patients with high mortality or high resource requirements from ICU care to do the most good for the greatest number of patients. In extreme circumstances, these protocols recommend withdrawing ICU resources from sicker patients in favor of more salvageable patients. However, if providers were to follow the earlier protocols in a disaster and withdraw and reallocate ICU care, criminal or civil liability could result. Two legal solutions to avoid this potential for liability have been suggested in this article.

Significant reduction of laboratory specimen labeling errors by implementation of an electronic ordering system paired with a bar-code specimen labeling process.

STUDY OBJECTIVE: We measure the rate of emergency department (ED) specimen processing error reduction after implementation of an electronic physician order entry system paired with a bar-coded specimen labeling process. METHODS: A cohort pre- and postintervention study was conducted in the ED during a 61-month period ending September 2008 in a large urban teaching hospital. Historically, laboratory order and requisition processing was done by hand. Interventions included implementing an ED-specific electronic documentation and information system, which included physician order entry with patient verification through bar-coded wristbands and bar-coded specimen labels. The main outcome measure was processing error rate, defined as unlabeled/mislabeled/wrong patient specimen or requisition. Pre- and postimplementation data were tabulated monthly and compared in aggregate by χ(2) test. The contribution of ED error to total institution specimen error was also calculated. RESULTS: Of the 724,465 specimens collected preintervention, 3,007 (0.42%) were recorded as errors versus 379 errors (0.11%) of 334,039 specimens collected postintervention, which represents a 74% relative and 0.31% absolute decrease (95% confidence interval 0.28% to 0.32%). The proportion of institutional errors contributed by the ED was reduced from 20.4% to 11.4%, a 44% relative and 9.0% absolute reduction (95% confidence interval 7.7% to 10.3%). Subanalysis revealed that the majority of continued errors occur when the physician order entry/bar-code system could not be used (eg, blood bank or surgical pathology specimens). CONCLUSION: Combining an electronic physician order entry with bar-coded patient verification and electronic documentation and information system-generated specimen labels can significantly reduce ED specimen-related errors, with sizable influence on institutional specimen-related errors. Continued use of hand labeling and processing for special specimens appears inadvisable, though the cost-effectiveness of this intervention has not been established.

An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers.

OBJECTIVES: The objective was to perform an epidemiologic study of emergency department (ED) medical malpractice claims using data maintained by the Physician Insurers Association of America (PIAA), a trade association whose participating malpractice insurance carriers collectively insure over 60% of practicing physicians in the United States. METHODS: All closed malpractice claims in the PIAA database between 1985 and 2007, where an event in an ED was alleged to have caused injury to a patient 18 years of age or older, were retrospectively reviewed. Study outcomes were the frequency of claims and average indemnity payments associated with specific errors identified by the malpractice insurer, as well as associated health conditions, primary specialty groups, and injury severity. Indemnity payments include money paid to claimants as a result of settlement or court adjudication, and this financial obligation to compensate a claimant constitutes the insured's financial liability. These payments do not include the expenses associated with resolving a claim, such as attorneys' fees. The study examined claims by adjudicatory outcome, associated financial liability, and expenses of litigation. Adjudicatory outcome refers to the legal disposition of a claim as it makes its way into and through the court system and includes resolution of claims by formal verdict as well as by settlement. The study also investigated how the number of claims, average indemnity payments, paid-to-close ratios (the percentage of closed claims that resolved with a payment to the plaintiff), and litigation expenses have trended over the 23-year study period. RESULTS: The authors identified 11,529 claims arising from an event originating in an ED, representing over $664 million in total liability over the 23-year study period. Emergency physicians (EPs) were the primary defendants in 19% of ED claims. The largest sources of error, as identified by the individual malpractice insurer, included errors in diagnosis (37%), followed by improper performance of a procedure (17%). In 18% of claims, no error could be identified by the insurer. Acute myocardial infarction (AMI; 5%), fractures (6%), and appendicitis (2%) were the health conditions associated with the highest number of claims. Over two-thirds of claims (70%) closed without payment to the claimant. Most claims that paid out did so through settlement (29%). Only 7% of claims were resolved by verdict, and 85% of those were in favor of the clinician. Over time, the average indemnity payments and expenses of litigation, adjusted for inflation, more than doubled, while both the total number of claims and number of paid claims decreased. CONCLUSIONS: Emergency physicians were the primary defendants in a relatively small proportion of ED claims. The disease processes associated with the highest numbers of claims included AMI, appendicitis, and fractures. The largest share of overall indemnity was attributed to errors in the diagnostic process. The financial liability of medical malpractice in the ED is substantial, yet the vast majority of claims resolve in favor of the clinician. Efforts to mitigate risk in the ED should include the diverse clinical specialties who work in this complex environment, with attention to those health conditions and potential errors with the highest risk.

Uncompleted emergency department care: patients who leave against medical advice.

OBJECTIVES: To compare the patient characteristics, clinical conditions, and short-term recidivism rates of emergency department (ED) patients who leave against medical advice (AMA) with those who leave without being seen (LWBS) or complete their ED care. METHODS: All eligible patients who visited the ED between July 1, 2004, and June 30, 2005 (N = 31,252) were classified into one of four groups: 1) AMA (n = 857), 2) LWBS (n = 2,767), 3) admitted (n = 8,894), or 4) discharged (n = 18,734). The patient characteristics, primary diagnosis, and 30-day rates of emergent hospitalizations, nonemergent hospitalizations, and ED discharge visits were compared between patients who left AMA and each of the other study groups. A Cox proportional hazards model was used to examine the influence of study group status on the risk of emergent hospitalization, adjusted for patient characteristics. RESULTS: Patients who left AMA were significantly more likely to be uninsured or covered by Medicaid compared with those admitted or discharged (p < 0.001). The AMA visit rates were highest for nausea and vomiting (9.7%), abdominal pain (7.9%), and nonspecific chest pain (7.6%). During the 30-day follow-up period, patients who left AMA had significantly higher emergent hospitalization and ED discharge visit rates compared with each of the other study groups (p < 0.001). Insurance status, male gender, and higher acuity level were also associated with a significantly higher emergent hospitalization rate. CONCLUSIONS: Patients who leave AMA may do so prematurely, as evidenced by higher emergent hospitalization rates compared with those who LWBS or complete their care.

Resuscitation attempts in asystolic patients: the legal tail wagging the dog?

In today's litigious society, legal worries can cause Emergency practitioners to alter their delivery of clinical care. One clinical scenario in which this particularly true is in resuscitation of the so called "medically futile" patient. Patients who arrive to the Emergency Department in prolonged asystole have a uniformly dismal prognosis at best. Yet, many Emergency Physicians often continue resuscitative efforts for fear of being sued. These fears are largely unjustified. This article attempts to analyze the factors and elements involved in support of the assertion that the risk of a lawsuit is negligible at best.