A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration

• Published in: Journal of patient safety Vol. 17; no. 8; pp. e898 - e903
• Main Authors: Gill, Sonia, Mills, Peter D., Watts, Bradley V., Paull, Douglas E., Tomolo, Anne
• Format: Journal Article
• Language: English
• Published: United States Lippincott Williams & Wilkins 01-12-2021; Copyright Wolters Kluwer Health, Inc. All rights reserved
• Subjects: Emergency Service, Hospital; Humans; Retrospective Studies; Root Cause Analysis; United States; United States Department of Veterans Affairs; Veterans Health; United States
• ISSN: 1549-8417; 1549-8425
• DOI: 10.1097/PTS.0000000000000636

BACKGROUNDPrevious work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety.
OBJECTIVESThe aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them.
METHODSRetrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015–2016) were coded by event type, root cause, and recommended actions.
RESULTSOne hundred forty-four cases were included for analysis. The most common adverse events were as followsdelays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%).
DISCUSSIONRoot cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.