EMERGENCY

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EMERGENCY MEDICINE EVENTS REGISTER A
Clinical Analysis of Procedural Errors Follow us
at _at_EmergMedER Visit us at
emer.org.au
Kim Hansen 1,2 Carmel Crock 3 Anita Deakin 4 Tim
Schultz 4 William Runciman 4 Andrew Gosbell5
1. The Prince Charles Hospital, 2. The
University of Queensland, 3. The Eye and Ear
Hospital of Victoria, 4. Australian Patient
Safety Foundation, 5. ACEM
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Introduction

• To capture and analyse adverse events, near
  misses and good saves that occur in Emergency
  Departments, we developed an online, anonymous
  incident reporting register called Emergency
  Medicine Events Register (EMER) at emer.org.au.
• Context This Patient Safety project is a
  collaboration between the Australasian College
  for Emergency Medicine (ACEM) and the Australian
  Patient Safety Foundation (APSF). It is aimed
  specifically at doctors of all levels who work in
  Emergency Departments.
• Problem Errors in medicine occur frequently and
  cause significant morbidity and mortality. Due to
  its chaotic nature, undifferentiated patients and
  variable levels of staff experience, the
  likelihood of patient harm in Emergency
  Departments is increased.
• Assessment of problem and analysis of its causes
  Doctors rarely report using existing incident
  reporting systems. We encourage doctors to make
  relevant and informative entries that their
  colleagues could learn from.

•  

Click HERE to go to emer.org.au
Follow us at _at_EmergMedER Visit us at
emer.org.au
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Methods

• We created emer.org.au which allows reporting of
  adverse events where information is confidential,
  protected and anonymous.
• Intervention At emer.org.au, the clinician
  remains anonymous and no patient or hospital
  details are recorded other than basic
  demographics. The website has a user-friendly
  design with only 4 pages of questions, most of
  which are drop-down boxes and non-compulsory.
  There is no registration, login or password
  required and the website is free to access.
• Study design The EMER website, emer.org.au, was
  designed with expert input from Emergency
  Consultants on the ACEM Quality Sub-Committee and
  APSF staff.  EMER was launched in November 2012
  and the website is open to for use by all
  Emergency Clinicians.
•  Analysis We analysed the data for the
  demographics of patients involved in an event,
  triage score, the time taken to complete and
  entry and the delegation of the reporting
  clinician. Entries into EMER were analysed by a
  panel of expert clinicians to determine the
  clinical category of the incidents.

Identify
Report
Improve
Learn more about EMER
Anonymous, Confidential and Protected
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Results
The first 246 entries into EMER via emer.org.au
from November 2012 to March 2016 were analysed.
Analysis results Each incident was categorised
into up to 4 categories, creating 473 categories
in total. The most common triage score was 3.
It took under 5 minutes to enter an incident on
average.
Categories of EMER Incidents (Total473)

• The most frequent incident categories are
• Diagnostic (n 95)
• Investigation (n 62)
• Procedure (n 53)
• There are multiple incidents of harm in the
  database, including eight deaths, and five
  incidents with irreversible harm to the patient.
  One staff member was electrocuted during a
  defibrillation.
• The most common procedural incident involved
  intubation. The other common procedural errors
  were intravenous access, ophthalmological
  procedures and procedural sedation.

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emer.org.au
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Procedural Errors
Case Study

• There have been 53 reports in the EMER database
  involving procedures. Within the procedural
  incidents, other common categories of error
  include Failure to recognise deterioration,
  Equipment, Medication, Transport and Diagnostic
  errors. There were several reports of patient
  harm, including
• 8 deaths
• 1 cardiac arrest and 1 respiratory arrest with
  successful resuscitation
• 2 oesophageal intubations
• 2 cricothyroidotomies and 1 needle
  cricothyroidotomy
• The most common role of the clinician involved in
  the incident was ED consultant, however over 95
  of reporters were ED Consultants.

• What happened?
• Patient deteriorated in ED acute area, with
  increasing SOB. Moved to resus. ED Consultant
  attempted to intubate with RSI but unsuccessful.
  Anaesthetist called, requested glidescope,
  anti-fog and glycopyrollate, all of which were
  unavailable in ED. Video laryngoscope used but
  battery ran out prior to first attempt.
  Anaesthetist unable to intubate patient in ED
  despite multiple attempts. Patient able to be
  ventilated with BVM.
• How could the incident have been prevented?
• Additional preparation time for anaesthetist and
  surgeon with earlier warning. Standardisation of
  equipment and processes in hospital.
  Inter-departmental education sessions.
• Action Taken
• Patient was transported to OT while being
  ventilated with BVM (satsgt90). He was gassed
  down by anaesthetist with surgeons scrubbed and
  neck prepped. Epiglottitis seen on glidescope.

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Conclusion

• The future for EMER Further awareness of
  emer.org.au to increase the number and quality of
  entries into EMER is the key to its utility to
  the profession. The expansion of the database
  will allow patterns of harm to emerge and allow
  EMER to educate its fellows and members on
  changes necessary to enhance patient safety.
  There is regular reporting of the EMER results
  back to the critical care community via Twitter,
  Patient Safety Alerts and other mediums. From
  March 2016, patients are able to report into EMER
  as well.

Click HERE to start video
There are lessons to be learnt from medical
errors. EMER provides the opportunity to
collect incidents which can be used to improve
patient safety.
Follow us at _at_EmergMedER Visit us at
emer.org.au