Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety – an analysis in a Finnish teaching hospital

Abstract

<div><h3>Background</h3><p>Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports.</p><p>The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety.</p><h3>Methods</h3><p>The study material included incident reports (<em>n</em> = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis.</p><h3>Results</h3><p>Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%).</p><p>In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems.</p><p>Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted.</p><p>Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding.</p><h3>Conclusions</h3><p>System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents.<br></p></div>