Gatefold
A guide to identifying and reducing errors in the emergency department
Hospital emergency departments are uniquely stressed. Not only is emergency medicine complex, but environmental factors in the ED—a steady stream of patients who demand immediate medical care, constant interruptions, multiple personnel involved in the care of a single patient—provide many opportunities for errors.
Hospital EDs are often overcrowded and understaffed. Visits to the ED increased by 20 percent in the last decade. According to the Centers for Disease Control and Prevention, there were nearly 114 million visits to EDs in 2003 (the latest year for which figures are available). A recent poll by the American College of Emergency Physicians found that seven out of 10 Americans believe emergency departments are approaching a crisis because of overcrowding.
Many of the patients coming to the emergency department have chronic conditions or are uninsured. At the same time, ED capacity has shrunk because of Medicare and Medicaid payment cuts. Nurses are scarce and specialist physicians increasingly decline to be on call at the emergency department.
It’s no wonder that patient safety in the emergency department is a challenge. In this gatefold, we look at why the emergency department is particularly vulnerable to medical errors, the kinds of errors that are likely to occur and ways to minimize them.
An analysis of 2,063 drug errors submitted to Medmarx, U.S. Pharmacopeia’s anonymous national medication error reporting database, showed that 77 percent of medication errors in emergency departments occurred during the prescribing and administering phases.
| Administration (1,081 errors) | 52.4% |
| Prescribing (508 errors) | 24.6% |
| Documenting (234 errors) | 11.3% |
| Dispensing (201 errors) | 9.7% |
| Monitoring (39 errors) | 1.9% |
Note: Does not add up to 100% because of rounding
| Number | Percent | |
| Improper dose/quantity | 491 | 24.0% |
| Prescribing | 357 | 17.4% |
| Omission | 357 | 17.4% |
| Unauthorized/wrong drug | 225 | 11.0% |
| Extra dose | 144 | 7.0% |
| Wrong patient | 133 | 6.5% |
| Wrong drug preparation | 88 | 4.3% |
| Wrong route | 80 | 3.9% |
| Wrong administration technique | 80 | 3.9% |
| Wrong time | 73 | 3.6% |
| Wrong dosage form | 22 | 1.1% |
*Does not add up to 100% because of rounding
Source: U.S. Pharmacopeia, 2003
In the ED, interruptions, intense pressure and a fast-paced environment can lead to medication errors, near misses, and fewer errors being intercepted. According to data submitted to U.S. Pharmacopeia, medication errors were only stopped from reaching the patient 23 percent of the time, compared with 39 percent of potential medication errors being caught for the hospital overall.
23% of the time medication errors were stopped in the ED before reaching a patient
39% of the time medication errors were caught in all hospital areas before reaching a patient
Emergency departments are swamped and patients are waiting. Only one in five people presenting at the ED is seen in less than 15 minutes. For most, the wait is hours long. And the longer patients wait, the lower their perception of quality.
| Number of visits | 113.9 million |
| Number of injury-related visits | 40.2 million |
| Most commonly diagnosed condition | acute respiratory infection |
| Percent of visits with patient seen in less than 15 minutes | 21% |
| Average time spent in emergency department | 3.2 hours |
| Percent of visits resulting in hospital admission | 14% |
Source: National Hospital Ambulatory Medical Care Survey,
Centers for Disease Control and Prevention, 2003
The emergency department is unlike any other area in the hospital. Workflow design, staffing, organizational factors and the physical environment impact both patients’ well-being and safety. The following factors are associated with increased risk of committing an error, and these factors commonly occur in the emergency care setting:
Sources: Emergency Nurses Association, 2006; American College of Emergency Physicians, 2001; H&HN research, 2006
“Delays in treatment” tops the list of sentinal events in the ED. This bar chart illustrates the top five sentinel events occuring in U.S. emergency departments between January 2001 and July 2005. The number of sentinal events occurring in each incident is shown in parenthesis.
| Assault/rape/homicide | 1.9% (3) |
| Restraint-related event | 3.1% (5) |
| Suicide | 8.2% (13) |
| Medication Error | 10.1% (16) |
| Delay in Treatment | 51.6% (82) |
Source: Joint Commission on Accreditation of Healthcare Organizations, 2006
In a survey of 393 full-time staff nurses, 30 percent reported making at least one error, and 33 percent reported at least one near-miss during a 28-day period of data collection. The most common type of errors identified by nurses included: medication administration, procedural, transcription and charting. Additionally, some nurses reported giving or almost giving the wrong medication.
Sources: Emergency Nurses Association, 2006; Applied Nursing Research, 2004; H&HN research, 2006
A review of nearly 11,000 records from 488 facilities in the MEDMARX medication error database between 1998 and 2003 showed that the products most frequently involved in errors were: heparin, insulin, ceftriaxone (an antibiotic), morphine and acetaminophen.
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Product Name
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Number of Errors
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| Heparin |
652
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| Insulin |
309
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| Ceftriaxone |
301
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| Morphine |
268
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| Acetaminophen |
223
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Source: U.S. Pharmacopeia, 2004
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Problems with technology
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For all its extraordinary benefits, new technology comes with unintended consequences, including the potential for unforeseen errors and other
problems that compromise patient care: |
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Technology that doesn’t link up
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Disorganization and workarounds
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Constant learning
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Individual pieces of medical equipment may not couple or communicate with other equipment. For example, blood pressure cuffs designed to fit only the same manufacturer’s machine.
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These result when equipment cannot be located in a timely manner or makeshift methods are used to accommodate an incompatible piece of equipment.
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New and complex medical equipment often requires current knowledge and experience for effective utilization.
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Sources: Emergency Nurses Association, 2006; H&HN research, 2006
The following are strategies to reduce or eliminate some of the factors that lead to errors.
Sources: American College of Emergency Physicians, 2005; U.S. Pharmacopeia, 2003; H&HN research, 2006
U.S. Pharmacopeia www.usp.org
Agency for Healthcare Research and Quality www.ahrq.gov
American College of Emergency Physicians www.acep.org
Emergency Nurses Association www.ena.org
Joint Commission on Accreditation of Healthcare Organizations www.jointcommission.org
Institute for Safe Medication Practices www.ismp.org
American Society of Health–System Pharmacists www.ashp.org
How We Did It: This gatefold was produced using interviews and research from the Joint Commission on Accreditation of Healthcare Organizations and the American College of Emergency Physicians, as well as research from the Center for Studying Health System Change, Emergency Nurses Association, and U.S. Pharmacopeia.
Research: Dagmara Scalise (dscalise@healthforum.com) Design: Chuck Lazar (clazar@healthforum.com)
This article 1st appeared in the May 2006 issue of HHN Magazine.
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