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					          Patient Safety

              in the

Emergency Department Environment

                           Patient Safety Task Force - 2001
                                      Patient Safety in the Emergency Department Environment

                                                                     Table of Contents
Preface by Robert W. Schafermeyer, MD, FACEP .......................................................................................3

Principles of Patient Safety in the Emergency Care Environment ................................................................5

Executive Summary .........................................................................................................................................7

     Patient Safety as a Core Value..................................................................................................................15
     The Environment.......................................................................................................................................15
     Crisis of the Uninsured .............................................................................................................................17
     Cultural Competence ................................................................................................................................17
     Crisis of Quantity ......................................................................................................................................18
     Culture of Emergency Medicine ..............................................................................................................18
     Patient Safety and the Emergency Medicine Resident............................................................................19
     Patient Safety and Emergency Nursing Profession .................................................................................19
     Patient Safety and Credentialing Bodies ..................................................................................................20
     Patient Safety and Clinical Policies and Guidelines ................................................................................21
     Taxonomy of Medical Errors ...................................................................................................................21
     Reporting Systems ....................................................................................................................................22
     Public Health ............................................................................................................................................25
     Error Reporting and Emergency Physician Wellness .............................................................................25
     Patient Safety and Out-of-Hospital Care..................................................................................................26
     Academic Affairs ......................................................................................................................................27
     Best Practices.............................................................................................................................................28
     Technology ................................................................................................................................................29
     Collaborative Priotities..............................................................................................................................33

Recommendations ............................................................................................................................................35
  Educational ..................................................................................................................................................36
  Best Practices .............................................................................................................................................37
  Policy ...........................................................................................................................................................38
  Operations ...................................................................................................................................................39
  Research ......................................................................................................................................................39
  Liaison .........................................................................................................................................................40
  Legislative and Regulatory .........................................................................................................................41

Conclusion ........................................................................................................................................................41


Recommendations Matrix ...............................................................................................................................44

Task Force Roster.............................................................................................................................................45

                                                                                                                                                                    Page 2

The core ethic of the practice of medicine, from its earliest days, has been “first do no harm.” Physicians
were to help patients, relieve pain, and repair injuries. But remember, do no harm. Over the centuries, the
practice of medicine slowly advanced. New theories, new medicines, new techniques and new
technologies improved the quality of care and the quality of life; each advance building on the previous
one. Methods that failed to do so, or that harmed the patient, were changed or stopped.

In the 1960s quality emergency care was not guaranteed when you entered a hospital’s emergency
department (ED). Variations in the quality of care were not intentional, but were the result of rapid
change occurring in society, physicians who were not prepared for the increasing severity and of illness,
and the growing complexity of medical and trauma care. Patients wanted access, consistency, and quality
emergency care. Physicians with a vision of a better way to provide such care founded the American
College of Emergency Physicians (ACEP) and the specialty.

There were improvements in emergency medical education, residency training was initiated, and
continuing medical education became more focused on the needs of physicians practicing emergency
medicine. There were advances in research, diagnostic studies and treatments. There were advances in
monitoring, technology and information systems.

Today the ED is part of a larger, complex system. Given the complexity of the system, for the thousands
of patients treated each day, there are many opportunities for medical errors, as well as opportunities to
reduce such errors.

The two Institute of Medicine (IOM) reports, “To Err is Human,”1 and “Crossing the Quality Chasm,”2
point out that there is not a well-oiled system in place with coordination of information, care and
technology. “The new report2 decrees that the nation’s health care industry has floundered in its ability to
consistently provide safe, high-quality care to all Americans and calls for a complete redesign of the
health care system as we know it.” according to Joanne E. Turnbull, PhD, Executive Director, National
Patient Safety Foundation (NPSF).

Outcome studies, evidence-based medical practice, and best practices are recent improvements, but not
fully accepted. Better information systems that can coordinate patient information, test results and
medications ordered are available but not widely used. Add to these basic system problems the current
health care crisis (as reflected in hospital closures, reduced funding, nursing and health care personnel
shortages, failure to implement information system improvements and redundancy in the systems to catch
errors), one can readily see that any patient, anyone of us, could easily become the victim of a medical

Safety is a critical component of quality health care. The second IOM report2 identified ten new rules to
redesign and improve care. One of the rules states that safety is a system property. “Patients should be
safe from injury caused by the care system. Reducing risk and insuring safety require greater attention to
systems that help prevent and mitigate errors.” Safe systems must be designed around human factors and
there must be system accountability not individual blame. The hospital system must be coordinated and
improved so that errors are reduced and quality of care is increased.

Quality of care is one of the reasons that the public fostered the development of our specialty. Safety and
quality patient care are central to our practice of emergency medicine. As advocates for quality,
emergency physicians are very knowledgeable of the changes needed to improve the overall system of
care provided in the hospital setting. The recommendations of the Patient Safety Task Force and the
Principles of Patient Care in the Emergency Care Environment are just the beginning of what our

                                                                                                      Page 3
specialty must do and where we must go in order to continue our efforts to enhance safety and provide
high-quality emergency care to every patient who seeks our services.

On behalf of the College, I thank the task force members for their diligent efforts to develop a road map
of quality patient care for the specialty of emergency medicine.

Robert W. Schafermeyer, MD, FACEP

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                   Principles of Patient Safety in the Emergency Care Environment

   Safe, timely, and quality emergency care is an essential component of health care.

   Adequate funding and resources must be available to support the emergency care structure.

   Improvement of patient safety in the emergency department must include but not be limited to:
    funding to support adequate staffing, integration of information systems, and implementation of
    educational efforts designed to improve patient safety.

   Efforts to increase patient safety must include the evaluation of its impact on all aspects of emergency

   A uniform lexicon on patient safety should be developed and accepted by agencies and providers.

   Systems for reporting of medical errors must focus on developing solutions to improving patient care.

   Efforts to collaborate with private and public agencies to promote patient safety are critical to
    improving the quality of emergency care.

                                                                                                        Page 5
Executive Summary

                    Page 6
Executive Summary

This executive summary contains an explanation of the critical challenges and possible solutions to the
issue of patient safety in the emergency department (ED). The emergency medicine community is
dedicated to providing high quality, safe care to our patients. Quality is at the very core of the mission3 of
the American College of Emergency Physicians (ACEP). This commitment to quality has affected each
and every one of the 103,000,000 episodes of care in America’s EDs in 1999.4 The IOM report, To Err is
Human,1 has led to the recognition that, due to the complex nature and pace of emergency care, there is
significant potential for errors in the provision of that care. The burden of those errors is felt by providers,
victims, families and society with serious health, ethical, financial, and legal implications. The Patient
Safety in the Emergency Department Environment Task Force acknowledges the challenge of creating a
culture of safety in the often-chaotic environment of the ED.

Among the factors contributing to the potential for errors in the ED are:
 The sheer number of patients cared for, often manifested as ED crowding;
 The complex needs - clinical, social, economic and psychological - of our patients and their families;
 The critical shortages of health care workers;
 The frequent distractions from task and the uncontrollable nature of the work flow;
 The growing number of uninsured that stretches the available resource capacity of the ED;
 Resource limitations – such as inpatient bed shortages, unavailability of specialty consultation,
  effective trauma care systems, shortages of mental health resources (especially for children)
  medication shortages (tetanus immunization, steroids, prochlorperazine), and others that are
  announced almost weekly;
 Increasing patient and family service expectations;
 The lack of reliable medical histories and established relationships between ED providers and ED
 Increasing regulatory requirements related to practice, licensing and billing requirements imposed by
  federal, state and local governments and accrediting organizations, such as JCAHO, NCQA, and
 The role of the ED as sole provider of health care to many individuals who have no other source of
  regular care; and
 The rapidly expanding knowledge base that challenges a specialty known for its breadth.

The challenge of reducing errors in a unique environment that is functioning as the safety net for the
entire health care system will be great. Based upon our safety net role, we must embrace safe practices
knowing the essential role the emergency departments play in the communities.

Critical Issues and Necessary Actions

The task force identified certain critical issues and activities that will be necessary in order to adopt safe
practices. These include:

   Modifying the culture of emergency medicine. Emergency medicine practice can be characterized as a
    practice with no boundaries, unexpected inflows and outflows, and decision making with little
    information. The very nature of emergency medicine practice will change with the adaptation of
    safety practices.

   Recognizing that the new culture of safety may affect those who seek to practice emergency medicine.
    The autonomy, the thrill of having to “expect the unexpected,” and the intellectual challenge of
    emergency decision – making are often cited as reasons for entering our specialty. The
    implementation of safe practices may have a profound effect on the attractiveness of emergency
    medicine as a career by those who follow us.
                                                                                                     Page 7
   Broadening the frame of reference for total patient care by the emergency physician. We can no
    longer think of the point of disposition as the end of our care for patients. We must begin to study and
    to follow up on what happens to patients after their interaction with us including those who are
    discharged, those who are admitted, and a new group, those who are awaiting admission in our

   Alleviating the current and future shortage of personnel, especially nurses, that threatens the very
    fabric of our practice. Emergency medicine is practiced as a team and the lack of adequately trained
    or seasoned professionals is affecting the safety of every patient for whom we care. As the number of
    patients seeking our care continues to increase, functions such as triage must be modified to protect
    patients who might suffer harm if care is delayed.

   Embracing changes in credentialing and certification that lead to life long competency and learning.
    The rapidly expanding knowledge base of medicine, the need to modify practices to reflect this new
    information, and the need to aid professionals in meeting this challenge fall to the leadership of our
    organizations. Best practices that seek to improve patient safety must be integrated into the fabric of
    our curriculum and scope of practice.

   Appropriately linking clinical policies and guidelines to patient safety is imperative. The adoption of
    well-developed, evidence-based guidelines will be essential as a mechanism to improve quality and to
    decrease errors associated with variability in practice. The movement from consensus-based medicine
    to evidence-based health policy is one that merits the attention of the specialty. Resource allocation
    decisions may soon be linked to adherence of guidelines. Perhaps the greatest effect of the report, To
    Err is Human,1 is in supporting the implementation of guidelines in the practice of medicine.

The Scope of Patient Safety as a Policy Issue

The task force benefited from representation from many entities in the emergency medicine community.
The breadth of the issue required input from many committees within the structure of ACEP. In addition,
a number of members with expertise in the area of patient safety also contributed to the effort. Members
of the task force and staff attended meetings or interacted with multiple government agencies; Department
of Health and Human Services (DHHS), Agency for Healthcare Research and Quality(AHRQ), and
Centers for Medicare and Medicaid Services (CMS); medical organizations such as the American
Medical Association (AMA), American Board of Internal Medicine (ABIM); private foundations such as
the National Quality Forum (NQF), National Patient Safety Foundation (NPSF) and the Anesthesia
Patient Safety Foundation (APSF); and other societies such as the American Hospital Association (AHA).
The task force monitored the development of patient safety legislation and regulations at the state and
federal level.

This type of broad activity is indicative of the scope of present and future similar complex policy issues
that concern emergency medicine. Developing and formalizing new mechanisms to foster this type of
intra-organizational and inter-organizational activity will be increasingly important for ACEP. A formal,
organizational quality agenda should guide this work.

Specific Policy Issues

The defining of medical errors and the standardization of taxonomy for research, policy development, and
implementation is at the foundation of quality of care and the management of errors. For example, if an
incorrect admitting diagnosis is defined as an error, it will profoundly affect our practice. Active
participation in discussions related to the taxonomy of errors and the lexicon that will be utilized in this
area is essential.

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The issue of medical error reporting systems and their design will continue to be at the center of the
regulatory agenda. How systems can integrate the need for accountability with a desire to collect data to
facilitate practice improvement and to diminish errors is yet unanswered. Emergency physicians will
again find themselves at the crossroads of increasing federal and state regulations that mandate reporting.
How and if that mandate will be funded is yet to be determined.

Many organizations are moving to adopt standards and regulations related to patient safety. The ones with
the greatest impact on our practice will be those promulgated by JCAHO. It has already been reported that
lack of an internal plan in the hospital setting to notify patients about medical errors is being considered
as a Type I violation. ACEP has a responsibility in guiding its members in meeting those standards. More
importantly, it must be ready to provide input regarding the appropriate use of these measures and the
potential impact they have on emergency medicine services.

The Research Imperative

The Society for Academic Emergency Medicine (SAEM) believed patient safety was such an important
issue that a summit was held in May 2000. The need to develop a research agenda that can answer
specific questions related to patient safety in the ED environment is imperative.

Testimony was submitted on behalf of the task force and ACEP to the Quality Interagency Coordination
(QuIC) Task Force of AHRQ at the first National Summit on Medical Errors and Patient Safety in
September 2000.5 This testimony reflects the need to fund research specific to emergency medicine. It
also argued that before any safety practice is instituted in the hospital, research must be done to recognize
the effect of said practice on the ED. An example is reducing nurse staffing ratios in an ICU that leads to
closed beds resulting in boarding of ICU patients in the ED.

The task force recognizes that large gaps exist in what we know and what we need to know regarding
developing methodologies for improving patient safety. The identification of those gaps can help
organizations develop and fund their research agenda in emergency medicine. These organizations
include AHRQ, National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC),
and private entities such as Robert Wood Johnson Foundation or the Kaiser Family Foundations.

Increasing collaboration and coordination between SAEM and ACEP will be necessary to further patient
safety research.

The role that the Emergency Medicine Foundation (EMF) can play in financing research on patient safety
should be explored.

Emergency medicine has unique expertise in using injury control models that could be translated into
patient safety. As strong proponents of prevention, emergency physicians can be leaders in this arena.

ACEP holds the value that “the best interests of patients are served when emergency physicians practice
in a fair, equitable, and supportive environment.”3 The development of educational meetings and
publications and facilitating dialogue about medical errors is within the purview of the College.

The Safety of the Practitioner

While much attention has been spent on errors and their effect on patients, little discussion has occurred
regarding the safety of the professionals working in the emergency care environment. If patient safety is
to improve, recognition of the need to create a supportive environment that values the safety and health of
physicians and other members of the emergency care team is essential. We need to move past the culture
of blame. Methodologies must reflect the need to support providers in the recognition, reporting,
disclosure, and remediation of errors.
                                                                                                      Page 9
The Out-of-Hospital Care Agenda

Many of our patients enter our departments by ambulance. ACEP has a long legacy of supporting the
provision of quality care in this setting. The report, To Err is Human,1 encourages the study of errors and
safety across clinical interfaces. One such important interface is between the hospital and the out-of-
hospital care providers. One criticism of the IOM report was that most of the data was from acute care
hospitals. It is imperative to position out-of-hospital care as an essential link to the community and an
integral site and partner for further research. Opportunities to partner with other entities such as the
National Highway Traffic Safety Administration (NHTSA) and the National Association of EMS
Physicians (NAEMSP) to develop patient safety practices in these settings must be seized.

The Culture of Safety

Emergency medicine has been active in improving patient care and reducing potential harm to patients. It
is now being asked to do more. It has been challenged by the report, To Err is Human,1 to facilitate the
adoption of safe practices by its members. The task force supports this expanded role for specialty

Creating a Culture of Safety in Residency Programs

If we are to embed safety in the culture of our practice, it must begin at the level of the training programs.
The culture must be one that encourages acknowledgment and evaluation of errors. It will be important
that residents obtain the skills to acknowledge, evaluate, manage, and prevent medical errors. One
challenge will be in finding the balance between increasing autonomy and responsibility while
maintaining appropriate faculty supervision.

The task force recommends that training programs focus on developing and adopting best practices to
lessen errors at the point of the transfer of patient care to consultants, private physicians, during change of
shift, or at the time of admission.

Best Practices

Rigorous standards must be applied before a practice meets the definition of a best practice. Even the
National Quality Forum labels its recommendations, “examples of safe practices that may prevent health
care errors.”6 This however does not preclude activity in this area.

ACEP and its partners can begin the process of searching for innovative practices, analyzing them, and
disseminating them to the emergency medicine community.
A recent report, Making Health Care Safer, A Critical Analysis of Patient Safety Practices,7 provides an
evidenced-based review of safety practices, many of which pertain to emergency medicine. One practice
recognized was that of using real-time ultrasound during central line placement. This information can
strengthen efforts to increase the use of ultrasound in the ED. Review of such recommendations must be
evaluated for relevancy and the results disseminated to the emergency medicine community. In this
example, it also may indicate the need to expand educational courses to include this technique. The report
also contains recommendations on x-ray interpretation and the important issue of errors related to shift
work. The task force recommends using ACEP’s website to inform members as to the existence of
important patient safety practices documents.

Team Models

Many of the recommendations for system improvements can be realized through the implementation of
teams. Many examples exist of how this implementation has successfully led to error reduction in other
industries. How we can expand the team model that is often used in trauma care should to be explored.
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Members of the College are recognized as having expertise in this area and can serve as a resource to
these efforts.

Technological Innovation

Many of the advances that will occur are based upon the integration of information management systems,
reference resources and computerized medication tracking systems. The employer-based group, Leapfrog,
is supporting and endorsing the implementation of a “computer order entry system.”8 Emergency
physicians already are being asked to participate in the development and use of these systems. There is
great hope and anticipation that other technology such as patient bar coding, electronic medical records,
and point of care medical information for providers will be developed for the ED environment. Partnering
with those entities that are developing these systems should be a priority.

It is recognized that medicine is practiced by human beings, and humans, by their very nature, are prone
to make mistakes. Emergency medical care is provided in a chaotic environment rife with competing
demands, frequent interruptions, constant distractions, and a paucity of vital data. Emergency care
providers are often stressed by overwhelming task demands, uncontrollable patient volume and acuity,
and circadian rhythm disruptions. While much research remains to be done, it is clear that technology will
play a vital role in mitigating these and other factors that can lead to errors in our EDs.


Throughout the work of the task force, the number of collaborative and liaison relationships in the area of
patient safety have continued to grow. No one organization owns the issue of patient safety. The scope of
these issues will require increasing collaboration across the boundaries of organizations in health care.
Collaborative efforts should include regulatory agencies at the state and federal level, other professional
societies and associations, foundations such as NPSF and APSF, innovators such as the Institute for
Healthcare Improvement (IHI), and public and private purchasers of health care. Emergency medicine
will benefit not only from these relationships on the patient safety issue but also in its efforts to affect
health care policy as a whole.

The second IOM report, Crossing the Quality Chasm2 recommends that private and public purchasers,
health care organizations, clinicians and patients should work together to redesign health care processes.
Emergency medicine must be represented in these discussions.

The Future

Our colleagues in anesthesia made the decision to establish the APSF9 in 1985. This foundation is often
referred to as the model that other specialty societies should follow. Its mission is that “no patient shall be
harmed from anesthesia.” A similar statement, “that no patient shall be harmed in the ED” could be the
mission of an “Emergency Medicine Patient Safety Foundation.” The task force strongly supports the
consideration of creating such an organization for emergency medicine. There is a precedent for this type
of independent organization, that of EMF. The scope of the safety issue and the need to work with all
organizations in the emergency medicine community mandates the examination of such an effort.


The task force was initially formed to respond to the report, To Err is Human,1 and to evaluate the need to
commit to patient safety strategies in emergency medicine. However, during its deliberations, the follow-
up report from the IOM’s Committee on the Quality of Health Care in America was released and
expanded the scope of the task force objectives. In many ways, the challenge to the medical community
by the follow-up report, Crossing the Quality Chasm,2 is of even greater importance to the future of the

                                                                                                       Page 11
practice of emergency medicine. The report challenges all of us to commit to making health care safe,
effective, patient-centered, timely, efficient and equitable.

   Safe - Emergency physicians have demonstrated a long-term commitment to safety.

   Effective - The movement to evidence-based medicine and the ongoing work of the College of
    developing appropriate clinical guidelines must be recognized. The College's liaison relationships
    with organizations working on performance standards are a testimony to this dedication.

   Patient-Centered - Emergency medicine was founded as a specialty in response to the needs of the
    patients in our communities. Our efforts in injury control, prevention, and most importantly our work
    on “Prudent Layperson” indicate a continued effort to respond to the needs of our patients. The
    “white hat” issues that we promote are a result of these efforts and are at the core of our profession.

   Timely - In few other fields is the issue of timeliness as important as it is in the ED. Overcrowding
    and diminishing resources are threatening our ability to provide timely care to our patients. Policy
    efforts linking this issue to the quality agenda will be helpful.

   Efficient - Efforts to increase the efficiency of our departments to provide optimal service and care to
    our patients are ongoing. During the 1999 flu season and the months following, we saw the effects of
    a health care system that cannot efficiently meet the needs of our citizens. The inability to obtain care
    when and where needed is contributing to increases in ED volume. It is hoped that many of the
    innovations that will come out of the medical error reduction movement may improve our ability to
    provide care more efficiently.

   Equitable - EDs, by professional mission and by the regulatory mandate of EMTALA,10 are perhaps
    the most equitable site of care in the US. This mission, however, is threatened by diminishing
    resources. Emergency medicine must be recognized and supported for its role in providing equitable
    care to all.

These six aims for improvement can represent the blueprint for safeguarding the lives of our patients and
our legacy of standing for quality care. We are well on our way to achieving these goals.

The quality agenda put forth by the Institute of Medicine presents an opportunity and a framework for
emergency medicine to embrace. If we pursue these goals, we can anticipate a bright future for
emergency medical care and a safer environment for our patients and colleagues.

                                                                                                     Page 12

         Page 13

The release of the IOM report, To Err is Human: Building a Safer Health System,1 in November 1999,
was a sobering commentary on the safety of the health care system. The ground swell of public response
and the movement toward efforts to reduce medical errors became an important issue on the national

The initial response in the provider community was one of distrust of the statistics and denial of the scope
of the problem. The realization that the fragmented, stressed system is leading to unsafe conditions is now
more widely accepted. The question remains of just how unsafe is the system. This uncertainty is
especially true in emergency medicine where little research has been devoted to this problem.

The first IOM report challenged specialty societies to formulate a strategy to help its members move
toward a culture of safety. The report recommended that each professional society should make a visible
commitment to patient safety by establishing a permanent committee dedicated to safety improvement.
The report stated the committee should:

   Develop a curriculum on patient safety and encourage its adoption into training and certification
   Disseminate information on patient safety to members through publications, special sessions at annual
    conference, and other venues.
   Recognize patient safety considerations in practice guidelines and in standards related to the
    introduction and diffusion of new technologies, therapies, and drugs.
   Work with the Center for Patient Safety to develop community-based collaborative initiatives for
    error reporting and analysis and implementation of patient safety improvements.
   Collaborate with other professional societies and disciplines in a national summit on this issue.

In March 2001, a follow-up report from IOM, “Crossing the Quality Chasm: A New Health System for the
21st Century,”2 was released. This report set an even more challenging agenda than the first report. It
challenges physicians, their professional organizations, and specialty societies to fundamentally change
the systems used in the provision of health care.

The report acknowledged that “Safety flaws are unacceptably common, but the effective remedy is not to
browbeat the health care workforce by asking them to try harder to give safe care. Members of the heath
care workforce are already trying hard to do their jobs well. In fact, the courage, hard work and
commitment of doctors, nurses and others in the health care industry are the only real means we have of
stemming the flood of errors that exist in our health care systems.” The focus in preventing errors has
moved to that of changing the cultures of our institutions to fully embody the principle of primum non
nocere, making patient safety a bedrock value. A natural consequence of this focus is the recognition that
health care services are not provided in a vacuum but provided by a team of caregivers, with human
flaws, using sometimes faulty processes within imperfect institutions.

This report examines aspects of emergency medicine that impact or are impacted by patient safety issues
including resource allocation, technology, research, the nursing shortage, the uninsured and best practices.
It concludes with short-term, intermediate and long-term recommendations for addressing this critical

                                                                                                    Page 14
Patient Safety as a Core Value

The safety of our patients is a core value of our members and of our organization. ACEP considers the
provision of high quality care to be at the core of its mission. In order for care to be high quality, it must
first be safe. The mandate to improve patient safety in the ED environment must be answered.

“Quality emergency care is a fundamental right and should be available to all who seek it.”
(ACEP Value Statement)3

Emergency departments are unique in their mandate to care for all who seek service. The ED serves as the
safety net in our communities; we are providers of safe, high quality care to many individuals, including
those who have no other source of regular health or medical care. This mandate carries with it a
responsibility to advocate for equitable, safe and effective care for all individuals who come to us.

“There is a body of knowledge relating to safety and quality unique to emergency medicine that requires
continuing refinement and development.” (ACEP Value Statement)3

Little research exists that defines safety issues in emergency medicine in our unique environment. ACEP
must recognize its leadership role in defining the problem and seeking solutions that ensure quality care.

“Quality emergency medicine is best practiced by appropriately qualified and credentialed emergency
physicians.” (ACEP Value Statement)3

Issues of provider competency and qualification must be addressed as part of the process of creating a
culture of safety. Efforts that support education, training, and continued competency are part of our
charge. The leadership in the institutions of emergency medicine is charged with working to ensure a safe
practice environment that is essential to safeguarding the quality care given to our patients.

“The emergency physician has the responsibility to play the lead role in the definition, evaluation and
improvement of quality emergency care.” (ACEP Value Statement)3

The policy issues that surround reports on patient safety and subsequent effects on our members mandate
that ACEP take a leadership role in this area. As the largest emergency medicine organization, we must
lead the effort for our members and work with our colleagues in emergency medicine to define the quality
agenda for the benefit of our patients.

The Patient Safety Task Force appointed by ACEP President Robert W. Schafermeyer is unique because
it brings to this issue the resources and commitment of ACEP, its members and representatives of other
emergency medicine organizations. In addition, the scope of this issue required that many ACEP
committees be involved in the work of this task force. What follows is a guide for organized emergency
medicine to use as we begin to fulfill our renewed commitment to patient safety.

The Environment

Medical errors, along with patient rights, are at the forefront of discussions about health care in America.
Although most of the published data on medical errors is based on inpatient populations, experts believe
that outpatient care, including emergency care, may be as error-prone as inpatient care. According to the
IOM report, To Err Is Human,1 medical errors are estimated to account for between 40,000 and 98,000
deaths and substantial morbidity and cost.

                                                                                                       Page 15
In 1999, according to federal data, over 103,000,000 visits were made to America’s EDs.4 Because of the
complex nature and pace of emergency care, there is significant potential for errors in the provision of
that care. The burden of those errors is felt by providers, victims, families, and society with serious health,
ethical, financial, and legal implications.

Among the factors contributing to the potential for errors in the ED are:
 The sheer number of patients cared for, often manifested as ED crowding;
 The complex needs - clinical, social, economic and psychological - of our patients and their families;
 The critical shortages of health care workers;
 The frequent distractions from task and the uncontrollable nature of the work flow;
 The growing number of uninsured that stretches the available resource capacity of the ED;
 Resource limitations – such as inpatient bed shortages, unavailability of specialty consultation,
  effective trauma care systems, shortages of mental health resources (especially for children),
  medication shortages (tetanus immunization, steroids, prochlorperazine), and others that are
  announced almost weekly;
 Increasing patient and family service expectations;
 The lack of reliable medical histories and established relationships between ED providers and ED
 Increasing regulatory requirements related to practice, licensing and billing requirements imposed by
  federal, state and local governments and accrediting organizations, such as JCAHO, NCQA, and
 The role of the ED as sole provider of care to many individuals who have no other source of regular
  care; and
 The rapidly expanding knowledge base that challenges a specialty known for its breadth.

One of the greatest threats to patient safety in the ED is the role it plays as the health care safety net for its
community. As a result of this role, ED crowding in many parts of the country and the complex issues
associated with it threaten providers’ ability to give safe, high quality care. EDs function as providers of
last resort in the community, fulfilling their legal requirements as well as their missions by providing care
to all those who seek it. The ED is the only place in American life where discrimination on the basis of
ability to pay for medical services is specifically prohibited by federal law.

The National Quality Forum has identified certain environmental factors that are associated with
increased risk of health care errors.6 These include:

       Many and varied interactions with diagnostic and/or treatment technology;
       Many different types of equipment serving similar purposes;
       Multiple individuals involved in the care of a patients;
       Multiple “hand-offs” of care;
       High acuity of patient illness or injury;
       An environment prone to distractions;
       Need for rapid care management and time-pressured decision-making;
       High volume and/or unpredictable patient flow;
       Use of diagnostic or therapeutic interventions having a narrow margin of safety, including the use
        of high-risk drugs;
       Communication barriers with patients and/or co-workers; and
       Inexperienced caregivers.

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Clearly, the ED fits all of these criteria. We must acknowledge these factors and move toward minimizing
errors related to them.

In testimony to the first National Summit on Medical Errors, Dr. Robert Wears, Chair of the SAEM Task
Force on Patient Safety, described the unique environment of the ED.11 He noted that the ED is a complex
and difficult environment in which to provide medical care and differs substantially from more traditional
settings in the organizational and cognitive burdens placed on caregivers. There are six aspects of ED care
that make it qualitatively different from care rendered in more traditional settings and make it more
vulnerable to error. While all are present to some degree in any care area, their magnitude and combined
presence in the ED give it unique characteristics that call for particular study and may provide insights
similar to those gleaned from study of expert performance in other uncertain, dynamic, and demanding
domains. These six factors include its unboundedness, multiplicity, uncertainty, severe time constraints,
lack of feedback, and little opportunity for practice.

These six factors are not the only ones that affect performance in the ED. Shift work and sleep loss are
contributing factors. Heavy dependence on services outside the ED (laboratory, radiology, consulting
services, etc.) also play a role in the potential for errors in care.

Since the level of training and qualifications of emergency caregivers has increased dramatically in the
past 20 years, the high rates of error in the ED would not seem to arise from less competent or committed
practitioners but rather from high levels of task complexity, uncertainty, multiplicity, and production

To paraphrase Gene I. Rochlin from his book, Trapped in the Net: The Unanticipated Consequences of
Computerization, for a caregiver in an emergency, unsure of context and pressed into action only when
something has already gone wrong, with an overabundance of some data but missing the rest and under
pressure to act quickly, avoiding a mistake may be as much a matter of good luck as good training.

Crisis of the Uninsured

Emergency departments are the de facto caregivers for many of the 44.3 million and growing uninsured
individuals in this country.1 Their lack of access to the normal channels of health care including routine,
on-going and follow-up care may compromise their ability to have their health care needs met. The
growing numbers of these patients and the non-existent or inadequate reimbursement to hospitals and
physicians may not allow for increasing the necessary resources to meet the demands. The mixture of
inadequate resources and system saturation creates a ripe environment for errors.

Cultural Competency

“Cultural competency” refers to understanding the values, ethos, language, and other aspects of culture
that contribute to the ability of an individual (in our case, an emergency physician) to appreciate the
experience of illness in patients who do not share the physician’s cultural background.

The lack of cultural competency can create barriers to care. The demographics of the US population, as
documented by the 2000 census, is changing. The challenges of cultural competency, already significant,
are likely to increase in the future.

English is not the first language for a significant number of patients. Effective communication with our
patients is the cornerstone of good care, and often emergency medicine physicians must rely on the non-
English speaking patient to provide the medical history of the illness. When the patient does not speak the
language of the physician, the potential for errors increases and the quality of the encounter suffers. It is

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unknown how many errors can be attributed to inadequate and/or incorrect translation in this setting.12 As
the nation’s population of immigrants rapidly grows, studying and implementing systems of care that
effectively address their needs must also be included in our efforts.

Initiatives that enhance cultural competency and communication, including recruiting greater numbers of
medical school students and graduates who represent a wide variety of cultures, can directly impact
patient safety in the ED. Increased support for translation services and discharge information in specific
languages need to continue at the local level.

Crisis of Quantity

It has often been said that the ED is the only limitless area of any hospital. The ED has little ability to
control its inflow or outflow. This characteristic, in conjunction with the closure of hospitals throughout
the country and the downsizing of inpatient bed capacity, has created a crisis of “quantity” in many EDs.

This fact can be illustrated by the events of the influenza season of 1999, where ED length of stay
increased to over 24 hours for many patients due to the lack of inpatient bed capacity. Admitted
emergency patients spent many hours awaiting inpatient beds. There was also an influx of individuals,
motivated by drug company advertisements of the newly available anti-influenza agents. The result was a
gridlock situation, leading to severe overcrowding in many EDs.

Emergency departments are not designed for and, in many areas, their staffs are not trained to provide
inpatient care. Research must be undertaken and systems developed to ensure that patients who are in
need of inpatient treatment can be safely and adequately cared for in the hospital. This must be a priority,
as policy issues; financial issues and population issues that lead to saturation are unlikely to change in the

The overcrowding of EDs will continue to affect the safety of care in the ED. Leaders in the emergency
medicine community agree that this is a great threat to patient safety.

Culture of Emergency Medicine

The culture of emergency medicine is one that functions on the edge of chaos as emergency staff attempts
to bring a microcosm of order to each patient The very nature of emergency medicine and the complexity
of its practice create challenges for those trying to implement changes and processes that support and are
driven by patient safety. As a specialty society, our ability to impact errors will be directly related to
developing and sharing best practices to facilitate this shift in culture.13 This shift has implications for our
emergency medicine residency training programs, continuing educational efforts, and our ability to work
with other organizations in emergency medicine.

The nature of emergency medicine is rapidly changing and evolving. Emblematic of this evolution is the
change in the nature of the place where emergency care is provided; that is, from “emergency room” to
“emergency department” and now includes free standing EDs that survived hospital closure. In other
areas, patients are now utilizing EDs as a type of community health care center. Often our perception, as
providers, of what constitutes emergency care differs from that of policy makers and patients. The rapidly
changing landscape of emergency care poses a barrier to developing one model for all institutions.

Our specialty must examine our own culture to determine what changes are needed to move toward a
“culture of safety,” “that is, a culture wherein safety is an abiding and built-in institutional universal
mind-set guiding all actions from the highest level policy-making to the bedside behavior. It presupposes

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an unwavering dedication to the principle, PRIMUM NON NOCERE - FIRST DO NO HARM. Second,
eliminate any potential for harm to the extent humanly possible.

A significant barrier to continuous quality care is the culture of emergency medicine itself. Emergency
medicine has often treated the time of discharge either to the outpatient or inpatient setting as the end
point for patient care. In the minds of most practitioners, the relationship with the emergency physician
terminates at this point. The outcome of the interaction is judged at the time of that disposition.

We traditionally have reviewed cases of returns to the ED within 72 hours and transfers to the ICU within
12 hours of admissions. In the old culture of blame, an informal process of hearing about our “disasters”
from the “upstairs staff” reflected an orientation toward blaming a provider. In a culture of safety, the
frame of reference of the emergency medicine provider must be expanded to include what happened to
the patient after they left the department. It is essential that we truly collaborate in non-blameful ways
with caregivers within the hospital setting (hospitalists, admitting/attending physician, intensivists, etc),
and/or with those in the outpatient setting (primary care providers, consultants, community referral
resources such as sexually transmitted disease clinics, etc). This “loop of continuous care” must be
established across specialties and across boundaries.

Patient Safety and the Emergency Medicine Resident

Many points of view have been expressed on the topic of medical errors and patient safety; however, one
group, relatively unseen and unheard, will be dramatically affected by changes in health care today. This
group consists of medical students and residents.

Many compete for a limited number of residency spots in the extremely competitive field of emergency
medicine. Many of the attractions of emergency medicine - those of interest to students selecting their field of
specialization and residents in training now - are likely to be heavily impacted by the emphasis on patient safety
and error reduction. These attractions to emergency medicine include “lifestyle,” the thrill of having to “expect
the unexpected,” the intellectual challenge of emergency decision – making, the “hands on” nature of the
treatment with frequent performance of complex and challenging procedures, the variety of conditions seen in
the patient population, the ability to make an immediate difference in an individual’s critical illness, and the
interaction with the various specialists.

With respect to the nature of residency training, where increasing levels of autonomy often accompany
the transition of residents from one year to the next, we must recognize that certain changes, such as in
practice and supervision, the use of redundant systems to reduce errors and others, may be perceived as
delaying or impeding the development of autonomy in practice.

Patient safety and error reduction may depend on reducing variation in practice, requiring more and better
communication from provider to patient, raising the standards of documentation, demanding ongoing and
regular recertification procedures, while simultaneously expecting greater productivity and “customer
service.” The nature of the practice of emergency medicine may change in ways unanticipated and
undesired by those entering the field today. For example, efforts to foster the use of protocols and care-
paths in settings where providers ordinarily functioned autonomously may face resistance from those
accustomed to using unbridled clinical acumen in treating critically ill patients

Patient Safety and the Emergency Nursing Profession

The current nursing shortage is having a profound effect on the ability to staff EDs (and other critical care
areas) with qualified, experienced nurses. The causes of the nursing shortage are many and varied. Fewer
people are entering the nursing profession and nurses are leaving the bedside for many reasons, including

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working conditions such as undesirable hours, understaffing, increased patient loads, poor pay and
benefits, work redesign, greater risks in the workplace In addition, nurses are getting older, with the
average age of nurses currently at 45.2 years. It is estimated that 40% of the nursing workforce will retire
in the next 10 to 15 years. Coupled with the need for more resources to care for the aging “baby boomer”
generation and the increasing complexity of patient care needs, the nursing shortage is reaching crisis
levels and is expected to get far worse before getting better.

In the ED, there are key places where the most experienced emergency nurse must be assigned. One such
place is at triage where the patient enters the system and the nurse independently determines if the patient
needs immediate medical attention or if the patient can wait. Other areas that require the expertise and
knowledge of an experienced nurse are in the trauma resuscitation room and in the “code room” where
critical care nursing skills are required. ED nurses must also have the skills to recognize subtle changes in
their patient’s condition that may not be easily noticed in the short time they are with them.

Preparation for a registered nurse to work in the ED requires at least one year of advanced training
beyond nursing school (diploma or bachelor degree) in order to gain proficiency in all areas of emergency
nursing care, which includes emphasis on triage, trauma, disaster preparedness, pediatric care, and the
psychosocial issues of patients in the emergency setting. However, with the nursing shortage, a new nurse
may not receive adequate orientation and follow-up to ensure he or she can practice safely.

Another result of the nursing shortage is the increased (and growing) use of temporary staff to fill the
vacancies. While many of these temporary workers are experienced emergency nurses, they are new to
the department and require closer supervision than the regular nursing staff. This also influences the
potential for error.

Numerous legislative initiatives are occurring that are designed to respond to this crisis.

The shortage of experienced nurses has a direct link to the quality of care that the ED can provide. This
issue is driving legislators in many states to define nurse-to-patient ratios. The lack of experienced nurses
also will have a profound effect on the triage process. If personnel don't have the experience or
knowledge to determine “who is sick,” protocols, procedures and processes will need to be developed to
set criteria for safe triage. It is imperative that ACEP work with the Emergency Nurses Association
(ENA) to frame the issue of adequate nurse staffing as a safety issue.

Patient Safety and Credentialing Bodies

To Err is Human1 included recommendations that are directly related to the issue of maintaining clinical
    “Recommendation 7.2 – Performance standards and expectations for health professionals should
    focus greater attention on patient safety. Health professional licensing bodies should:

            Implement periodic re-examinations and re-licensing of doctors, nurses, and other key
             providers, based on both competence and knowledge of safety practices; and

            work with certifying and credentialing organizations to develop more effective methods
             to identify unsafe providers and take action.”

Board certification is often looked upon as a gold standard of quality by hospitals and managed care
entities. This has also led to increased scrutiny of the process and meaning of board certification. There is
acknowledgement that passing a didactic exam at set intervals is only one piece of competency. The

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movement toward continuous competency is directly linked to efforts in assuring the competency of
physicians and other providers.

Emergency medicine will need to aggressively create and implement an ongoing competency and
certification model. In addition, as knowledge base and best practices develop in the area of patient
safety, knowledge of safe practices will become an element of credentialing and testing. Curricula on
patient safety for graduate and post-graduate training will need to be developed and implemented.

Patient Safety and Clinical Policies and Guidelines

Practice guidelines (also referred to as clinical policies, clinical protocols, care pathways) play an
important role in promoting patient safety. Practice guidelines have long been promulgated by medical
societies, governmental bodies, and other interested parties.

Motivations for developing guidelines have been many and varied but commonly have included areas in
which there have been wide variations in the treatment of conditions with high risk for adverse patient
outcomes. The last decade has seen a widespread increase in the development and publication of these
guidelines. Although such guidelines should intuitively improve patient care and patient safety, there is
limited evidence demonstrating the degree to which they have done so thus far. Such studies are not only
difficult to design and execute, but there has been little funding support for conducting such research.

A major problem identified with the development of practice guidelines is the difficulty getting
practitioners to appreciate, understand, and use them in daily practice. This issue has been addressed to a
degree by patient care systems that incorporate the essence of a guideline into a system (either paper-
based or computer-based) that provides prompts to a care provider as the care is being delivered. An
additional problem is that for any practice guideline to have validity, the methodology of its development,
including the motivation of the developing group, must be explicit and consistent with quality care. As
imperfect as they are, practice guidelines remain among the best mechanisms to apply current medical
knowledge to ongoing patient care, allowing us to improve the delivery of quality and safety of patient

Increasing emphasis is now being given to quality, performance, and outcome measurement. Clinical
policies, guidelines, protocols, rules, and care-paths will play an increasingly important role in the future.
Physicians and other providers will be held to these as “standards of care.” At the national policy level,
efforts are underway to establish that lack of adherence to guidelines is the equivalent of a medical error.

Safety must be imbedded in all clinical policies as they are developed. The development of practice
guidelines for specific diseases or conditions (e.g., acute coronary syndromes) must be a priority in the
emergency medicine community. We should collaborate with our colleagues in other fields when the best
care requires interfacing with other specialist providers. Our input must reflect the specific quality issues
indigenous to our practice setting.

Taxonomy of Medical Errors

The issue of developing taxonomy for errors is an important one. The emergency medicine community
will not have an opportunity to lead in the development of these definitions, however emergency
medicine can position itself to participate in this work. Currently, the leaders are government agencies or
panels (such as IOM and AHRQ) and private regulatory agencies (JCAHO) as well as by organizations
within the provider communities and academic institutions.

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The emergency medicine community must recognize that all definitions are not equally acceptable and
have a methodology for evaluating definitions relating to patient safety. In addition, there is a need to
have a standard set of definitions for research purposes, database activities, and reporting requirements
facilitating the ability of the emergency medicine community to work collaboratively in this area.

The task force agreed upon the following criteria for a definition to be considered:

   Explicit - A definition should be clear and succinct. A definition that is unambiguous and concise
    will facilitate consistent case finding and enable aggregate analysis of trends.
   Valid - A definition must accurately reflect reality or truth, based on some combination of consensual
    and empirical validation.
   Important - A definition should specify the occurrence of an event or outcome that is clinically
    significant and can be changed by clinical intervention.
   Recordable - A definition should lend itself for use in ongoing data collection. The criterion or
    criteria embedded in the definition should be reported consistently and in a form that is readily
    accessible from one or more data sources.
   Reflects variation - A definition should be useful in evaluating an event or outcome that varies
    among patients and will be most useful when a substantial proportion of the variation is attributable to
    differences in patient care practices or resources.
   Stable - A definition should be constant over time and provide a basis for evaluating temporal trends
    of an event or outcome.
   Efficient for use in screening - A definition must help ensure that time and resources are used as
    efficiently as possible in achieving the optimal balance of such characteristics as sensitivity,
    specificity, and predictive value in screening for the event or outcome of interest.13

The College has actively participated in forums regarding the development of reporting systems. An
important part of this activity is related to the taxonomy of errors. Efforts should be made to monitor the
environment to recognize a standard set of definitions that we can support. How we define errors is at the
heart of the patient safety debate.

Reporting Systems

The most extensively discussed and controversial policy issue is related to the recommendations for the
reporting of medical errors. The task force recognized the purpose attached to the reporting will determine
what needs to be reported and under what conditions. Reporting for accountability will require different
systems and data than reporting for learning. Designing a system that does both will be a challenge.

Reporting for accountability should be physically, logically, and administratively separated from
reporting for learning or there will not be sufficient trust in the system for people to comply. Billings
(architect of NASA’s Air Safety Reporting System) has pointed out that in the end “all reporting is

Reporting in the sense of counting events in a large database can contribute to safety in two ways. First, if
we can define the correct reportable events, it can tell us whether or not we are “winning” over time.
Second, it can identify emergent properties that cannot be discerned from inspection of individual
instances. For example, the knowledge that the annual volume of procedures performed was important for
good outcomes of coronary artery bypass graft (CABG) could only have been identified in this way.
Detailed investigation of individual cases would probably not have demonstrated this fact.

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One potential outcome of the reporting issue that has not received much discussion is the idea of
organizations competing on safety. One could posit that if organizations are to compete on the basis of
safety, they will be less likely to share information that leads to improvement, and thus the safety
improvements will be limited. The airlines have carefully avoided this trap to a large degree. They
compete on schedule, price, and service, and have a tacit agreement not to compete on safety because
ultimately that approach would make them all less safe.

The design, development, and control of reporting systems continue to be a major challenge. The
questions of whom will have control of the system and how the federal and state systems will link has yet
to be answered.

Significant questions related to access and the use of patient safety data and information are being raised
in many forums, especially with regard to the Health Insurance Portability and Accountability Act
(HIPAA). The intent of HIPAA is to protect the privacy of patient records and medical transactions. It
will be difficult to reconcile this goal with the conclusion stated in Crossing the Quality Chasm2 “that
error reduction and quality improvement efforts will require open access to patient records and
transparency of data.”

Information technology systems will need to be developed and new policies and training will be required
to comply with the many issues surrounding medical records and how they interplay with patient safety.
The issue of who will fund these initiatives has yet to be answered.

Federal Reporting Systems

At the federal level, work continues on developing a model for a national reporting system. On April 23-
24, 2001, CMS, CDC, FDA, and AHRQ held a National Summit on Patient Safety Data Collection and
Use to discuss the model being developed for a national data collection system for medical errors.

Secretary of Health and Human Services, Tommy Thompson, acknowledged the need to streamline
activities at the Federal level and unveiled a new cooperative group, the “Patient Safety Task Force.”14 In
2001, President Bush's budget proposal includes $75 million for error reduction efforts. This amount is an
increase over last year and signals the administration’s support of these activities.

Secretary Thompson also stated that the initial charge to this Patient Safety Task Force would be to
coordinate the collection of data that is already being gathered and to develop architecture for future
reporting. He stated the system must be less burdensome, provide reliable information, maintain
confidentiality, and provide those submitting data with feedback and access.

This group will also spearhead demonstration projects that will identify risks and provide solutions. A key
issue is how a model that will link federal and state data systems will be built. This model must include
the de-identification (meaning the removal of personal individual identifiers) of data to be transmitted.

Discussion included the need to incorporate providers in designing the system and the need to make it an
error reduction tool and not a punitive or blame tool. The group consensus was that the system could only
be built if data gathered was confidential, it carried legal protection for reporting activities, and its initial
goal was research and data collection for learning. If a system was to be a tool for accountability too soon,
participation would be hampered.

It is also recommended that the data collection interface at the provider level would be through an
independent entity and not a state regulatory agency. This interface would be similar to the Federal
Aviation Administration (FAA) model.

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State Reporting Systems

In efforts to study states that already had reporting programs, it was noted that the existing programs were
not designed to capture medical errors. In addition, they lacked standard definitions and had significant
differences in how data are gathered and used. No consensus occurred on the disclosure of information or
how to protect information from disclosure. No reliable methodology existed for defining the basic
number of reports. As a result of this variability, the National Academy for State Health Policy has
published a document to aid states in dealing with these issues.15 “In general, there is no vehicle around
which to organize state activities on patient safety.”

The issue of privacy has been the most controversial issue in many states. Deciding whether and how to
protect system data from public disclosure and legal discovery involves balancing the public's need and
uses for the information with provider concerns about the legal consequences of making information

The evolution of reporting systems and the requirements linked to them will continue to be a policy issue.
ACEP will need to continue participating in the design and continue its role of educating members in this
area. The possibility exists that a variety of strategies will be implemented at the state level. This
approach is likely to result in unfunded mandates. It is important that ACEP utilize its resources to
monitor this issue and to aggressively assist chapters in participating in legislative and regulatory efforts
in every state.

JCAHO Standards Related to Patient Safety

New patient safety standards went into effect on July 1, 2001, that will require hospitals to initiate
specific efforts to prevent medical errors and to tell patients when they have been harmed during their
treatment from a medical error.16

The new standards underscore the importance of strong organizational leadership in building a culture of
safety. Such a culture should strongly encourage the internal reporting of medical errors and actively
engage clinicians and other staff in the design of remedial steps to prevent future occurrences of these
errors. The additional emphasis on effective communication, appropriate training, and teamwork found in
the standards language draws heavily upon lessons learned in both the aviation and health care industries.

Another major focus of the new standards is on the prevention of medical errors through the prospective
analysis and re-design of vulnerable patient care systems (e.g. the ordering, preparation and dispensing of
medications). Potentially vulnerable systems can readily be identified through relevant national databases
such as JCAHOs Sentinel Event Database or through the hospital's own risk management experience.

The standards make clear the hospital's responsibility to tell a patient if he or she has been harmed by the
care provided. How one defines harm is less clear. It has been recommended reporting begin with “should
never happen events” and/or sentinel events.

Hospitals will have to make efforts to meet these reporting standards. ED staff and administration will be
asked to play an active role in these initiatives. These standards will have an immediate impact on our
members and their clinical practice. Educational efforts related to the dissemination of these standards
and their impact on emergency medicine will be an important task for ACEP.

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In testimony to the First National Summit on Medical Errors, Dr. Robert Wears, Chair of the SAEM Task
Force on Patient Safety, describes the current scientific knowledge and the need for future directions in

Dr. Wears states “There have been few focused investigations of errors and adverse events occurring in
the ED, and even fewer into their nature, triggering and contributing factors. What is available in the
literature offers tantalizing glimpses of the problem but does not provide a great deal of understanding
into the origin, manifestation, recognition, prevention or mitigation of errors.”

Research in the area of patient safety in the ED environment must be given high priority. Continued
efforts, including funding to support patient safety research, is necessary.

Public Health

The merits of incorporating a public health approach to patient safety are well worth considering. This
approach is guided by a set of epidemiological principles and an emphasis on prevention and early
intervention that have led to notable successes in reducing the burden of hospital infections, motor vehicle
crash injuries, household poisonings, and other major health problems in the US. The concepts and
strategies of public health are readily grasped by emergency physicians who in recent years have moved
to the forefront of such fields as injury prevention and control and disaster preparedness and response.
The idea of addressing patient safety problems in emergency medicine through an approach that has a
strong scientific foundation and a proven track record makes sense to practitioners and policymakers
alike. ACEP is encouraged to incorporate a public health orientation to the fullest extent possible.

Error Reporting and Emergency Physician Wellness

While much has been written regarding the cognitive aspects of decision-making and the importance of
systems management and process improvement as approaches to reducing medical error, little
consideration has been given to the emotional impact of errors and near-misses on the practitioner.
Evidence exists that errors are common in clinical practice and that physicians often deal with them in
dysfunctional ways. However, there is no general acknowledgement within the profession of the
inevitability of medical errors or of the need for practitioners to be trained in their management. These
concerns are particularly relevant to the practice of emergency medicine where physicians are called upon
to make time-critical decisions on multiple patients, frequently based on limited information in an
environment fraught with the potential for making errors.

A review of the recent medical literature reveals growing interest in how physicians find healthy ways to
deal with their medical mistakes and adverse outcomes in their patients. While there is no consensus as to
a single approach, several specific measures have been recommended.

       Accept responsibility for the mistake. There is evidence that those physicians able to accept
        responsibility for their mistakes appear more likely to make subsequent constructive changes in
        their practice.
       Discuss with colleagues. The tendency for physicians to bear the burden of their mistakes in
        isolation has been noted in several studies. Yet physicians report having strong needs for personal
        validation, reassurance, and professional reaffirmation under these circumstances. Most express a
        desire for discussion with and support by colleagues. The formation of support groups adapted to
        this purpose has been suggested.

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       Disclose and apologize to the patient. The physician is bound by the ethical principles of non-
        maleficence, beneficence, and respect for patient autonomy and justice to disclose errors that
        cause or may cause harm to a patient. While some legal authorities caution that, as a practical
        matter, such a disclosure may increase the risk of litigation and the adverse outcome of same,
        there is evidence that lack of candor regarding medical mistakes is one of the major reasons that
        patients proceed to litigation and that disclosure of mistakes may, under certain circumstances,
        actually strengthen the physician/patient relationship. Legal considerations notwithstanding, the
        prospect of disclosing a mistake to a patient is clearly a painful one.
       Conduct an error analysis. An important part of a coping strategy in dealing with mistakes is
        the process of analyzing the mistake intellectually, using any lessons learned to promote
        professional growth. This practice may lead to changes in systems design or professional practice
       Develop an emotional coping strategy. Medical errors can have an emotional impact on
        practitioners that can last for years. Several techniques have been successfully utilized by
        physicians in processing the emotional impact of their errors. The steps discussed include
        disclosure to colleagues, patients and family. Additionally, a focus on self-forgiveness as well as
        acts of expiation (such as extra attention to the family) were found to promote emotional healing.
       Make changes in practice or practice setting design to reduce future errors. Modification in
        diagnostic or therapeutic techniques, more attention to details and screening, closer attention to
        trainees and staff, improved documentation, and developing good communication skills are
        examples of practice changes to be considered in preventing future errors.
       Work at local and national levels to change the culture of the medical profession with
        regard to the management of medical mistakes. Physicians individually and within their
        medical groups should foster an environment in which errors are openly acknowledged,
        systematically analyzed, and ethically managed. Continuous quality improvement efforts should
        include written policies for addressing mistakes.

We must acknowledge the inevitability of medical mistakes and of the need to provide resources that
educate and support emergency physicians in dealing with the emotional consequences. A national
support group to provide counseling and advice could be established. Educational meetings could be
developed that include lectures and panel discussions on the ethical and emotional aspects of dealing with
medical errors. Research in the areas of systems analysis and coping techniques specific to the specialty
of emergency medicine could be promoted.

The movement toward disclosure may be in direct conflict with some principles of risk management.
Recent developments within the patient safety movement suggest a shift in attitudes toward disclosure by
insurers and institutions.

Patient Safety and Out-of-Hospital Care

The report, To Err is Human,1 encourages the study of errors and safety across clinical interfaces with
EDs. One important interface is between the hospital and the out-of-hospital providers. One criticism of
the IOM report was that most of the data was from acute care hospitals. It is imperative to position out-of-
hospital care as an essential link to the community and an integral site and partner for further research.

The ED, hospital, EMS systems, and providers must participate in the study and reduction of errors. The unique
position of EMS providers poses special considerations and opportunities for error reduction. The linkage
between the staffing and resource availability in the ED and the care of patients by out-of-hospital providers in
the community is readily apparent to those who practice in the ED. Practices such as nurse/staff ratios can
ultimately have unintended consequences in this sector of health care. If ICU beds are closed due to lack of

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staffing, the trickle down effect may be that an ambulance that is bypassed to a remote facility will not be
available to provide lifesaving care in its own region. Our efforts to ensure rapid response for such emergencies
as cardiac arrest will be affected. It is imperative to link an intervention to the unexpected consequences in the
whole health care continuum.

The EMS needs of communities differ greatly depending on many factors including demographic,
geographic, epidemiologic, economic, and political. In EMS, improving care must, of necessity, take into
consideration local realities. This approach will be likely to succeed of a broad range of health care
institutions, EMS organizations, and providers are encouraged to participate in designing studies that take
such factors into consideration. Knowledge of many different locales and the special needs and
considerations relevant to them should be fostered. To accomplish this objective, EMS oversight agencies
and government must fund innovative projects sponsored by both traditional and non-traditional research
partners. The NAEMSP or EMS systems might represent such non-traditional partners.

Funding must be available not only for research but also implementation of recommended improvements.
Unfunded mandates will not help improve quality.

Out-of-hospital care will face its own stresses and issues related to the error reduction movement. As in
other areas of EMS, research is imperative. Emergency medicine must expand its own safety efforts to
include the out-of-hospital care setting.

Academic Affairs

Currently, emergency medicine residency programs do an excellent job in providing residents with the
knowledge and clinical skills necessary to practice emergency medicine in an independent and competent
fashion. In the future, it will be equally important that residency programs equip residents with the skills
necessary to acknowledge, evaluate, manage, and prevent medical errors. Areas of focus unique to
emergency medicine residency training include:

       Developing and maintaining a culture within residency programs on how to properly evaluate and
        manage medical errors. Through clinical teaching and personal example, faculty must create an
        atmosphere within residency training that encourages the acknowledgement and critical
        evaluation of error. This practice will require a change in mindset from ignoring minor medical
        errors to attempts to solve the problem by identifying an individual physician to blame (culture of
        blame). The emphasis will need to be on identifying and correcting system errors.
       Incorporating into the didactic portion of the residency curriculum a discussion of common errors
        or mistakes that occur in the evaluation and/or treatment of specific disease processes and injury.
        This discussion should become a standard portion of every didactic lecture, similar to
        presentations on pathophysiology, diagnosis and complications. Morbidity and mortality
        conferences offer an excellent opportunity to critically evaluate medical errors and discuss system
        design changes to prevent future error.
       Finding the balance between allowing residents increasing autonomy and responsibility
        throughout their training while maintaining appropriate attending faculty supervision will be a
        particular challenge. Solutions will need to incorporate the existing tiered structures of
        responsibility (medical student, intern, junior resident, senior resident and faculty) traditional to
        most training programs. As residency programs develop effective mechanisms (best practices) to
        address this issue, they will need to be shared among program directors.
       Focusing on areas particularly vulnerable to medical error such as the transfer of patient care
        from the emergency physician to consultants or private physicians during change of shift,

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        admission, etc. Residency programs will need to focus on this area and teach residents how to
        minimize error related to the transfer of patient care.

Best Practices

The development, recognition, and dissemination of best practices in patient safety is in a very early
stage. As research in the area of patient safety becomes available, it is expected that ACEP will play a key

The Task Force recommends that the definition for a ‘Best Practice’ is “one that is shown to reduce the
risk of error occurring or preventing or minimizing the impact of an error on the patient.” Until such time
that best practices are developed that can pass rigorous scientific examination, a number of tools or
practices to improve patient safety have been recognized. They run the gamut from practices that may
improve patient safety to true best practices.

A recent report from AHRQ, “Making Health Care Safer: A Critical Analysis of Patient Safety
Practices”17 released in July 2001 details an analysis of basic safety practices and the evidence supporting
them. It lists 73 safe practices that are likely to improve patient safety, and describes 11 that the
researchers considered highly proven to work, but are not performed routinely in the nation's hospitals
and nursing homes. One of their recommendations of particular interest to emergency medicine is the use
of ultrasound to help guide the insertion of central intravenous lines. It has been demonstrated that using
this technology prevented punctured arteries and other complications.


Teamwork is an essential element in highly effective organizations, including those in the nuclear power
and airline industries as well as in elite military units. Teamwork has enabled these fields to achieve
enviable records in safety and performance. The IOM reports frequently refer to the importance of the
team approach to enhancing patient safety.

The use of the word “team” is often used but not well articulated or practiced. The most successful
organizations teach teamwork and develop teams in a very structured way. Health care and medicine are
generally lacking in such training or in-depth understanding of how to build and develop teams.
Teamwork is more than organizing people into specific groups. There is a distinction between “teams”
and “groups.” Teams are distinguished by four essential elements:

       A common purpose;
       Interdependent actions among members;
       Accountability as a functioning unit; and
       Value for collective effort (synergy).

Where used effectively in medicine, the benefit of teams and, more importantly, teamwork is to:

       Increase staff and patient satisfaction;
       Improve performance;
       Decrease errors; and
       Decrease costs, especially in terms of “risk.”

Team approaches are likely to be critical to enhancing the safety of patients. Successful teamwork
requires the implementation or reinforcement among medical professionals of what teams are and how

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they are constituted. This approach often requires a change in the mind set of the physician trained in the
“captain of the ship” mindset. Performing as a team requires very concrete changes such as establishing
teams in each specific work environment, recognizing the variables of demographics, skill sets, individual
strengths and weaknesses, and patient and staffing patterns. It also requires more abstract consideration of
roles, values, focus, and perceptions in the daily work environment. It requires a reliance on team skills
(not just individual skills) that are not inherently known or well taught in medical school. Leadership,
situational awareness, cross monitoring, task assistance, and appropriate challenges are all part of a
complex structure that enhance performance and assist maintaining teams.

Effective models of teamwork demonstrate that practices can become proactive instead of reactive,
support is mutual, information is effectively shared, quality is improved, and individual achievements
refocus on team achievements. All of this comes at a price both financial and personal. Developing
teamwork is hard work and will fail if not properly supported.

Commercial training programs are available at different costs. These programs range from those that
make everyone feel good, but accomplish little, to those that require hard work but can make a difference.
Considerable literature is available to help self motivators in developing individual programs. Teamwork
is the direction in which medicine must move to be most effective in dealing with often overwhelming
work environments with more demands, fewer resources, and the need for improved efficiency.

Care in the ED is provided by a group of highly skilled workers in an environment of unpredictability.
Emergency medicine must give high priority to efforts that support research into the development and
implementation of models that improve team performance and diminish errors.


As a result of the uncontrollable patient volume, high acuity and complexity of illness and injury, and
frequent lack of longitudinal patient data, emergency medical care presents unique patient safety
challenges. However, these challenges provide opportunities for development and testing of patient safety
strategies that can meet the specialized needs of the ED and be generalized to other, less acute, areas.
Clearly, technology holds significant promise in this regard.

Computerized Physician Order Entry Systems

Medication error, the number one source of medical error,18 is perhaps the area in which technology can
have the greatest benefit. Many influential groups including the IOM, the Leapfrog Group, and the federal
government, have emphasized the importance of “smart” computerized physician order entry systems
(CPOES). These systems combine the benefits of computerized order entry by physicians with real-time
clinical decision support. As a result, the implementation of such systems has become a strategic priority
for almost all hospitals and health care enterprises. While such systems hold enormous promise and
appear simple conceptually, they are incredibly complex and expensive to design, implement, and
operate. These systems can only be successful when there is a free flow of data between the CPOES and
other computer systems. However, such connectivity is often limited by system architecture, data
definitions, and the privacy and security requirements contained in regulations such as HIPAA. The
challenges are greater yet in the ED where patient volume, acuity, and geography can stress any order-
entry results reporting system to its limits.

The most intelligent human being is able to consider only five or six independent variables at any given
time to make decisions.19 However, in the clinical setting, the health care provider is often bombarded by
thousands of data points that compete for attention. At the same time, crucial pieces of data may be
hidden beyond a firewall, in an inaccessible database, or in a paper chart that cannot be located in a timely

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manner. The risk of medical error increases substantially when key data is either unrecognized by or
unavailable to the treating physician. “Smart” CPOESs, combined with sophisticated electronic medical
records (EMR) systems, may prove extremely valuable in this regard.

“Smart” CPOESs tap these data streams and, through the implementation of established rules, extract and
organize data so that it can be analyzed for specific conflicts or potential errors. This information is then
presented to the physician in a rational and organized manner to enable efficient, effective, and safe
medical decision making.

While CPOES implementations are enterprise-wide endeavors, the ED environment presents several
unique challenges to system designers. On hospital floors, patients are usually bedded into a specific
location where they stay for relatively long periods of time. At most, an inpatient bed changes occupancy
once or twice in a 24-hour period. However, in the ED, beds turn over rapidly and patients often start out
in one location only to be moved to a second or a third during their relatively short stay (i.e. pelvic exam
room, suture area, x-ray, monitored bed, observation bed, etc.). Because the CPOES and emergency
health care providers rely on accurately identifying both a patient and their location, patient mobility in
the ED presents yet another opportunity for error (i.e. medicating wrong patient because of location
change between order entry and order execution).

Technology offers several opportunities to limit such potential errors. The simplest approach is to bar
code both the patient and the medication and require scanning/matching of both prior to drug
administration. Similar safeguards can also be implemented for other potential error sources such as
specimen collection and test performance. This system works well when drugs are prepared in the
pharmacy or under controlled circumstances by a nurse at a nursing station where labels can be printed
and applied to the medication. However, this system tends to be especially cumbersome when patients are
critically ill. In fact, patient urgency frequently forces ED caregivers to bypass all medication
administration safeguards in order to resuscitate a patient in a timely manner. Alternative approaches
during resuscitation include stocking crash carts with pre-mixed, standardized unit doses of resuscitation
medications and placement and use of dosing calculators on the carts. Ideally, these units would be
interfaced with the master pharmacy system to look for allergies and potential drug interactions.

Computerized Tracking Systems

Computerized patient tracking systems are used in the ED to both identify patients in an electronic
environment and to assign them to physical locations. They provide important safeguards in the order
entry – treatment delivery process. In an environment where patients frequently move from bed to bed
during a single visit, such systems help assure that the lab test, x-ray, or treatment ordered on a patient is
actually provided for the intended patient. The tracking system provides an electronic link to the CPOES
and can incorporate bar coded error checking techniques as described above. Tracking systems can be
either active (i.e. all patient movements are tracked and recorded by staff making entries in the computer
system) or passive (i.e. technologies including infrared (IR) and radio frequency (RF) are used to track
most movements/interactions without active input from ED staff).

EMS systems strive to deliver the right patient to the right facility at the right time. To do otherwise might
prove dangerous for the patient. Smaller hospitals and those without a specific commitment to the care of
certain critically ill and injured patients routinely transfer complex patients to larger referral centers.
However, increasingly, ED saturation and the lack of inpatient hospital beds force EDs, large and small,
to divert ambulances and refuse transfers. This situation makes it difficult for pre-hospital and ED
personnel to determine the right destination at any given time. Web-based, community-wide, real-time
tracking system that monitors the status of ED and hospital resources are being developed to address this

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Electronic Template Charting Systems

Patient care in the ED is carried out in an often-chaotic environment rife with competing demands,
frequent interruptions, and constant distractions. Electronic template charting systems hold significant
promise for linking bedside care and documentation to clinical and quality assurance guidelines. Such
systems, which are just now starting to come to market, use a problem or complaint-based template to
document a patient’s history, physical exam, test results, response to treatment, medical decision-making,
and disposition arrangements. Linkage to clinical and continuous quality improvement (CQI) protocols
can provide real time prompting to improve clinical practice, expand differential diagnoses to include
problems that might otherwise be overlooked (i.e. pulmonary embolism), and improve documentation and
reimbursement. These systems must generate reports that convey important information in formats that
are usable by others who will need to deal with the record (i.e. patients, primary care physicians, other
emergency physicians, managed care reviewers, coders, etc.) These systems must also interact
electronically with the hospital EMR to both access and automatically incorporate important preexisting
data (i.e. medication list, allergies, etc.) and deposit data and reports from a ED visit to the EMR. As will
be discussed below, it is also critical that data collected during the ED visit be EMDS/DEEDS compliant.

Electronic Medical Record (EMR) Systems

Health care is one of the most information-intensive service industries. The practice of medicine is
dominated by how we process information, how we record information, how we retrieve information, and
how we communicate information.20 Emergency health care workers are among the most information-
intensive health care professionals. They require immediate access to information because of the demand
for rapid and intensive diagnosis and treatment of patients, 24-hours a day, whenever the patient chooses
or the condition mandates.21 Emergency departments treat a heterogeneous, undifferentiated patient
population. In many cases, important historical information is unavailable to the treating physician.
Patients often forget key details of their medical history or are too ill or injured to provide any
information at all. Because emergency care is, by its nature, episodic, emergency health care providers
usually have no prior knowledge of individual patients or their “baseline.” As a result, ED physicians
often work “on fumes” or the “faintest whiffs of information.”

The urgent need for information frequently results in a “shotgun” approach to testing when, in retrospect,
certain tests would not have been necessary had the physician had access to prior results or past history.
This “shotgun” approach is reinforced by the demand, both from patients and administrators, to quickly
arrive at a disposition. Even when information is available, it may not be available quickly enough. Either
the patient’s condition is so acute as to require action before data is available or the time lost waiting for
the data outweighs the disadvantages of repeating tests or gathering information again. Furthermore,
because most health care information systems are “islands of information,” unconnected to other systems,
sharing information between hospitals, private offices, and clinics is often problematic. To further
complicate information access, even information within a single institution may be scattered among an
“archipelago” of databases. Finally, because most emergency medicine information management is
currently paper-based, information is typically slow to retrieve, often illegible, and difficult to share.21
Alper summarized the current situation best when he wrote, “Episodic care starts at the beginning, again
and again.”22

From a patient safety perspective, every roadblock to critical data access represents an opportunity for
error and patient harm. Time to data acquisition can be critical. Each test that is repeated provides myriad
opportunities for injury and error in the sampling, testing, and reporting processes. Even more concerning,
critical pieces of data may never become available.

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Enterprise or community-wide electronic medical record (EMR) systems can significantly limit this
problem. Furthermore, robust EMRs are critical to the success of “smart” CPOESs. However, patient
confidentiality, incompatible computer systems, scarce human and financial resources, politics, and
inadequate institutional commitment have stifled their creation. Even in institutions with robust EMRs,
there is only limited ability to share critical data with those outside the institution’s firewall. Such
limitations present unique challenges to EMS systems and EDs as patients are triaged based on acuity,
geography, and special capabilities, not insurer, primary care physician, or location of past medical
records. As a fall back, systems using “smart” cards have been suggested. With these systems, patients are
provided with wallet cards that contain electronic versions of potentially critical information. Patients
control who they give the card to, and EDs provide appropriate “readers” for the data. Unfortunately, such
systems have proven ineffective due to both insufficient mass and complex logistics. At this point in time,
many experts feel the best solution to this problem lies in the creation of a “voluntary,” web-based,
emergency medicine EMR.

Significant effort and federal funding have been dedicated to the creation of such a web-based EMR.
Essential Medical Data Set (EMDS), developed by the National Information Infrastructure Health
Information Network (NII-HIN), is a standardized data set containing the data elements most needed by
physicians during an emergency encounter.23 It includes demographics, problem lists, medications,
allergies, and previous critical encounters. It is not intended to be a complete medical record but, rather, a
compilation of those elements of past medical history that will yield the highest benefit in an emergency
situation. At the same time, the National Center for Injury Prevention and Control has developed the Data
Elements for Emergency Department Systems (DEEDS).24 Unlike EMDS, which focuses on a concise
medical history data set, DEEDS produces a data set that describes a single emergency encounter. These
processes use identical data definitions for common data elements and are designed to complement each

Should such a system be instituted on a regional or national basis, it will address many of the critical
information needs that currently endanger ED patients. When a patient presents to an ED that participates
in such a system, the patient will grant permission to have his data extracted from the EMDS data
repository. If the patient is not an EMDS participant, he/ she will be given the opportunity to join. The
local ED will then electronically link, in a secure manner, to the regional EMDS database and download
any available historical data into their DEEDS-compliant EMR. If there is no EMDS data stored
regionally (i.e. the patient is from another part of the country), the EMDS system will query other
regional EMDS databases until a data source is found. During the course of the patient’s ED visit, data
will be stored in the hospital’s DEEDS-compliant emergency medicine EMR. Upon completion of the
visit, the regional EMDS repository will be updated to reflect the new emergency visit, medication
changes, and other such information.25

Online Education and Reference Materials

Emergency medicine is practiced in a fast-paced, geographically limited environment. Practitioners
seldom have the luxury of being able to go to the library to read up on a problem or check a fact about
which they have some doubt (i.e. is the forehead involved or spared in Bell’s Palsy?). Access to a good
online reference library and the vast resources available on the Internet is an inexpensive yet invaluable
investment in quality patient care. Online contemporaneous consultations (i.e. EKG / x-ray interpretation,
etc.) through the internet can help avoid dangerous medical errors. Many excellent CME sites are
available online, and, in the future, the same rules engines that power “smart” CPOESs will be used to
provide just-in-time, context sensitive CME during the physician’s most teachable moment.

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Human Factors and Technology

Emergency medicine is practiced by human beings and humans make mistakes. Human factors, the
interaction between humans, the tools they use, and their environment, play a role at some level in almost
all medical errors.1 Emergency medicine practitioners provide care in an “interrupt-driven” manner,
responding to multiple competing demands, frequent interruptions, and constant distractions. A recent ED
study found that almost half of all physician tasks are interrupted and 2/3 of the interruptions resulted in
task changes. The number of task changes correlated positively with the number of patients managed
simultaneously.26 Studies in the airline and nuclear power industries have shown that task interruptions
play a major role in a significant number of accidents. While there are no good studies to confirm that
interruptions cause errors in medicine, it is reasonable to assume that the same relationship exists.26
Changing tasks interrupts the internal “to do” list that most physicians use to carry out complex tasks. The
development of computerized, context sensitive “to do” lists, generated from data in the EMR or the
CPOES, might prove valuable in mitigating the adverse effects of task interruptions.

Circadian rhythm disruption and extended time on task are important human factors associated with
increased risk of error.27 It is hard to imagine any group of medical providers more affected by these
human factors than those who provide emergency medical care. Because there is ample literature
regarding these factors including optimal scheduling patterns and work rules,28 it is reasonable to assume
that computerized scheduling programs can be developed to enforce rules that minimize these risks for
both patients and providers.


Emergency medical care is provided in a chaotic environment of competing demands, frequent
interruptions, constant distractions, and a paucity of vital data. Emergency care providers are often
stressed by overwhelming task demands, uncontrollable patient volume and acuity, and circadian rhythm
disruptions. While much research remains to be done, it is clear that technology will play a vital role in
mitigating these and other factors which can lead to errors in our EDs.

Many of the advances that will occur in the area of patient safety will involve or be facilitated by
technology. This technology must however be designed for and integrated into the special ED
environment. Meanwhile, our existing systems must be improved so that their limitations do not cause
harm while we await the advent of appropriate technology.

Collaborative Priorities

The issue of patient safety is being addressed by many organizations that are influential in health policy.
It will be necessary to have a coordinated strategy to evaluate and plan how ACEP can best interact with
these entities. In many cases, the College is already actively engaged in these collaborative relationships.

Joint Commission on Accreditation of Healthcare Organizations
In 2001, JCAHO put into place new standards that are directly related to patient safety. These standards
will have an immediate and strong impact on hospitals and emergency medicine.16 The Joint Commission,
because of its unique role in evaluating and for accrediting hospitals, has the great potential to drive the
safety agenda.

ACEP representatives to JCAHO must be vigilant regarding new initiatives that will affect the day to day
practice of emergency medicine. The emergency medicine community must become aware of these
standards and familiar with processes such as Root Cause Analysis that are utilized in the Sentinel Event
Reporting activities.

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The National Patient Safety Foundation29
National Patient Safety Foundation (NPSF) is an organization that plays a key role in the elucidation of
the causes and dissemination of practices which will lead to reduction in the frequency and severity of
errors. Founded in 1997, the NPSF is an independent, nonprofit research and education organization. It is
an unprecedented partnership of health care practitioners, institutional providers, health product providers,
health product manufacturers, health care liability insurers, researchers, legal advisors, patient/consumer
advocates, regulators, and policy makers committed to making health care safer for patients. The NPSF
has sponsored ground-breaking conferences on the subject of medical error. It also was the source of the
paper, “Current Research on Patient Safety in the United States.” An active listserv is maintained by the
organization for the purpose of linking interested parties in the pursuit of error reduction processes and
strategies. Its most recent activities have been in the area of medical error disclosure.

ACEP currently has a liaison relationship with the NPSF.

National Quality Forum30
The National Quality Forum (NQF) is a not-for-profit membership organization created to develop and
implement a national strategy for health care quality measurement and reporting. A shared sense of
urgency about the impact of health care quality on patient outcomes, workforce productivity, and health
care costs prompted leaders in the public and private sectors to create the NQF as a mechanism to bring
about national change.

A 19 member Board of Directors representing health care consumers, purchasers, providers, health plans,
and experts in health services research governs the NQF. The Board includes representatives from two
federal agencies, the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care
Financing Administration (HCFA), and the AHRQ. Members of the Forum, voting through Member
Councils, have elected four members of the Board.

The Forum has also convened a standing panel of leading experts in quality improvement and
measurement to identify the principles and priorities that will guide a national measurement and reporting
strategy. Building on this effort and the work of public and private quality improvement organizations,
the Forum will endorse quality measures for national use. The Forum will also promote the use of quality
information and develop a research agenda to advance quality improvement.

Many of the individuals with the expertise and commitment to drive a quality health care agenda are
involved at the highest levels of the organization. The broad range of participants in the forum, and its
link to policy makers will continue to mean that it is influential in the area of patient safety.

The Institute for Healthcare Improvement
Institute for Healthcare Improvement (IHI) is working to accelerate improvement in health care systems
in the US, Canada, and Europe by fostering collaboration among health care organizations.

IHI provides forums at which people and organizations that are committed to health care reform and
performance improvement can share ideas and work together. Examples of their work are the
“Breakthrough” series - dedicated to the development and sharing of ideas for performance improvement
in various health care venues, e.g., the ED, operating room, other areas of the hospital, and its “Pursuing
Perfection Initiative.” IHI maintains archives of ideas presented and publications derived from these
programs. IHI has been an important organization leading change in performance improvement in health
care and driving the process improvement, error reduction and safety agendas. ACEP members have
actively worked with IHI on its breakthrough projects. A wealth of innovative techniques and practices
that will be useful to members would come from this collaboration.

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Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ) , formerly known as the Agency for Health
Care Policy and Research (AHCPR), is a division of the US Department of Health and Human Services.
Its mission is to support research designed to improve the outcomes and quality of health care, reduce its
costs, address patient safety and medical errors, and broaden access to effective services. The research
sponsored, conducted, and disseminated by the AHRQ provides information that helps people make better
decisions about health care. Further, it maintains a database of and updates clinical practice guidelines,
provides evidence-based information on health care outcomes, quality, cost, use, and access.

The agency was established in December, 1989, as the AHCPR, a Public Health Service agency in the
DHHS. Reporting to the DHHS Secretary, the Agency was reauthorized on December 6, 1999, as the
AHRQ. Its most recent budget was $269.9 million. Nearly 80 percent of AHRQ's budget is awarded as
grants and contracts to researchers at universities and other research institutions across the country.

AHRQ is responsible for setting the research agenda in patient safety. ACEP and SAEM have been
actively participating in its efforts.

The Leapfrog Group8
The Leapfrog Group is a group of business entities who are members of the Business Roundtable,
representing large purchasers of health care. They are actively trying to leverage their role in moving
hospitals to adopt safe practices.

Leapfrog purchasers are advancing three initial recommendations to improve patient safety:

       Computer physician order entry (CPOE);
       Evidence-based hospital referral (EHR); and
       ICU physician staffing (IPS).

These recommendations are well suited to patient safety because:

       There is scientific evidence that avoidable danger could be significantly reduced;
       Their implementation by the health industry is feasible in the near term;
       Consumers can readily appreciate their value; and
       Health plans, purchasers, and consumers can easily ascertain their presence or absence in
        selecting among health care providers.

Many of the policy initiatives in the area of patient safety, are being driven by these business entities. It is
imperative that the emergency medicine community not only monitor these activities but also actively
work with them to improve the safety and quality of emergency care.


The Patient Safety Task Force recognizes that the work of developing a culture of safety in the
approximately 5000 EDs of this country has only begun. For some time, ACEP has participated with
other specialty societies, regulatory agencies, both governmental and non-governmental, other
organizations and institutions concerned with the safety of patients. What follows is a suggested path that
ACEP and the other organizations that participated in the task force could follow to improve patient
safety. It is broad and far- reaching, and will require new approaches to working both within our
organization and with others.

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Many of these recommendations can be used as a guide to responding to the challenge of the IOM report,
“Crossing the Quality Chasm.” Quality is indeed one of the biggest issues facing emergency medicine.
Safety is a fundamental aspect of high quality care. Our greatest challenge will be in defining, defending
and disseminating the quality agenda for emergency medicine.

Educational Recommendations

Short- Term

  ACEP Website
  The Task Force has noted in order to reach members, one central location that coordinates patient safety
  information, activities and updates is essential. It will raise the visibility of ACEP’s commitment to
  safety to those outside of the organization and improve the value of membership by providing timely,
  updated information to members.

  Website links
  Much of the information that the task force shared and utilized came from outside groups such as
  NPSF, AHRQ, IHI, or NQF. If a member is to keep up to date on patient safety as a policy issue, it will
  be necessary to continue this process. Therefore we recommend that a separate area of the website be
  devoted to patient safety and that important links to organizations and documents be maintained.

  ACEP News
  As the most frequently read and widely distributed publication of the College, it is imperative that
  members receive information on patient safety in this venue. The task force felt that we should provide
  some “low-hanging fruit” recommendations to the emergency medicine community through articles on
  patient safety. ACEP should consider a series of articles on safe practices and issues similar to the
  reimbursement and ethical dilemma features.

  Educational Meetings
  The IOM recommended that specialty societies assume the task of educating members on safety issues.
  This role is especially important in light of the fact that it takes many years for a “best practice” to be
  accepted. Specific efforts to include patient safety issues at Scientific Assembly are already happening.
  An update could be included in the agenda at the Leadership and Legislative Issues Conference.


  Patient Safety Newsletter
  The Anesthesia Patient Safety Foundation (APSF) has a very successful newsletter. The purpose is to
  educate members about new issues and new advances in safety. A similar newsletter could be
  developed at ACEP. One option would be to make it available to interested members in an electronic
  format. It could have a similar format to Foresight and offer CME credits.

  Patient Safety at ACEP Meetings
  An “Annual Report to the Membership” on the subject of quality in emergency care is recommended. A
  commitment to hold a special “keynote” session on patient safety at each Scientific Assembly would be
  appropriate. The format could mirror the one that the Secretary of DHHS gives to Congress each year.

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Long Term

 Independent Emergency Medicine Patient Safety Foundation
 An independent Emergency Medicine Patient Safety Foundation would guarantee a long-term
 commitment to safety. Modeled after the APSF, this organization could maintain its independence and
 focus on ways to improve the safety of emergency patients without the potential of being diverted from
 its goals by changes in the agenda at ACEP or the larger emergency medicine community. Quality care
 is at the core of our organization and this entity would illustrate a dedication to quality and safety
 similar to the support of EMF.

 An educational meeting dedicated to quality and patient safety.
 Political and regulatory forces are moving toward a more focused effort in defining and reimbursing for
 quality care. An annual educational meeting (such as hot topics) could be developed to educate
 members on these issues. Subject matter would go beyond patient safety to the larger realm of better
 quality emergency care.

 Separate website for emergency medicine patient safety
 A separate website for safety issues could be developed. This would most likely occur in the setting of
 the EMPSF. A separate website that would allow all emergency medicine organizations to support its
 content and mission could become the “forum” in the emergency medicine community.

Best Practices Recommendations

Short Term

 Define Best Practices
 Although many suggestions have been put forth as best practices, there has been little attempt to impose
 scientific rigor on the evaluation and development process. Best practices must derive from the research
 agenda and be shown to be evidence-based. There must be continuous efforts to monitor the
 environment as best practices are defined, developed, refined, and implemented.


 Recognize Best Practices
 The Board of Directors has already been approached for partnering and/or recognition of products that
 are related to patient safety. It has been the experience of the task force that many of the initiatives and
 products related to safety (including processes) will not be in the public domain. Therefore, the College
 will need to develop policy for dealing with proprietary aspects of patient safety enhancers.

Long Term

 Disseminate Best Practices
 The College should develop a methodology for the dissemination of these practices. This dissemination
 could occur in a similar fashion to that of the clinical policies, in Annals of Emergency Medicine. In
 addition, the College should develop a method for monitoring best practices from other organizations
 within and outside of health care.

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Policy Recommendations

Short Term

 Policy on Reporting of Medical Errors
 A policy was presented to the ACEP Board of Directors for review and action at its September 2001

 “Talking Points” on Patient Safety
 The College currently has a document addressing this issue. Supporting efforts to educate 911
 Legislative Network members, media spokespersons, and the general membership to the “message”
 should be undertaken.

 Summit on Patient Safety with NPSF
 Although the task force had many representatives of the ED community, others did not participate. In
 order to further the patient safety agenda, the task force strongly recommends a summit on patient
 safety. This summit would include representation from other entities that interact with emergency
 medicine such as payers, government, NHTSA, and those that are setting the policy agenda.

 Develop Sentinel Event List for Emergency Medicine
 The JCAHO has identified certain events that should never happen. ACEP should develop its own list
 of sentinel events.

 Clinical Policy on Safe Practices at the Time of Transfer of Care
 One of the areas at highest risk for error is that of patient hand-off. It is recommended that safe
 practices be developed that aid in the transfer of care between providers in the ED, between the ED and
 consultants, and between the ED and admissions.

 Clinical Policy on Safe Practices Related to Patients Awaiting Admission
 ACEP is actively seeking solutions to aid in the disposition of patients who are forced to wait in our
 departments prior to admission. Until such time as these solutions are in place, members have asked for
 guidance in developing methods to safely care for these patients.


 Monitor Member Activity
 During the course of the work of the task force, many members have offered to participate, to lend
 expertise, or to discuss best practices. In our participation in other forums and with the government
 agencies, we found a number of emergency physicians, members and non-members, with expertise in
 the area. A methodology to identify individuals whose expertise could serve the College should be
 developed to foster their participation in patient safety initiatives.

 Serve as a Clearinghouse for Testimony
 Members of ACEP and the emergency medicine community have provided testimony to regulatory
 agencies and legislatures across the country. On such a complex issue, the College should collect this
 testimony and make it available for use by other members.

                                                                                                 Page 38
Long Term

 Collect data on medical errors
 The College continues to find that it needs data in order to support its policy initiatives. The College
 should consider becoming the defining entity for the data collection agenda. It also could become the
 repository of this data and center for data analysis.

Operations Recommendations

Short term

 Quality Steering Group
 The Patient Safety Task Force is comprised of individuals with expertise in patient safety and/or
 representing organizations in the emergency medicine community. It has acted as a strategy group and
 an initial forum for exploring the issues of patient safety. Its charge has been completed. It is
 recommended that it not be continued in its current format. The first IOM report recommended that
 professional societies develop a standing patient safety committee.

 ACEP needs to develop a quality agenda that reaches across the breadth of the organization. The task
 force determined that this issue is only one of many quality issues that we will be facing over the next
 few years. Our work indicates that input from all areas of the College will be necessary to continue
 addressing patient safety issues. A quality steering group that initially focuses on quality care and
 patient safety should be considered.

Long Term

 Independent EMPSF
 The patient safety initiative could be spun off into a separate entity that has strong ties to ACEP and
 other emergency medicine organizations. This entity would require its own endowment, budget, and

Research Recommendations

Short Term

 Endorse and Support SAEM Research Documents
 ACEP should endorse the work of and collaborate with SAEM and ABEM in efforts to define and
 promote the educational agenda related to patient safety, to sponsor research in ways to improve patient
 safety including human factors in emergency medicine that impede and promote quality of care and
 safety, and continue to support research in physician burnout.

 Monitor Available Funds and Grants
 The task force agrees with SAEM that the research agenda will be driven by private and governmental
 grants. The task force has argued at QuIC and AHRQ that emergency medicine should be a research
 priority. ACEP should publicize opportunities for research by traditional participants and non-
 traditional ones. Monitoring the available funding and opportunities and communicating this
 information to the emergency medicine community should be a priority.

                                                                                                    Page 39

 Partner with SAEM
 A more formal liaison relationship with SAEM with an emphasis on patient safety should be developed.
 The first IOM report looked to specialty societies to partake in research efforts and such a collaboration
 would be one way to support them.

 EMF - Designated Area of Research
 ACEP should work with the EMF Board to determine if targeted support for a researcher or research in
 this area is feasible.

Long Term

 ACEP Patient Safety Research Grants
 ACEP has received grants from the Department of Defense (DOD) and NHTSA. ACEP should
 independently develop a research agenda and apply for support from agencies such as AHRQ. It could
 participate in cross- specialty or outpatient research projects. This initiative would require the greatest
 commitment of resources of the organization. Other professional societies are entering this area.

Liaison Relationships

Short Term

 National Patient Safety Foundation - NPSF
 Active participation is recommended. NPSF is the leading organization in patient safety and has
 representation from the house of medicine, other health care providers, and institutions, as well as many
 businesses, government agencies, educational institutions, regulatory, and credentialing bodies.

 The Institute for Healthcare Improvement - IHI
 The work that is going on at IHI is significant and is at the level closest to implementation. Although
 the College has several members that work with IHI, the task force recommends a formal relationship.
 This relationship is essential to truly having an impact on patient care and safety in the ED.

 Joint Commission on Accreditation of Healthcare Organizations - JCAHO
 Decisions and policies from JCAHO have a direct and rapid impact on our members. The College
 should develop its ongoing advisory relationship with JCAHO to assure that “standards” are effective in
 enhancing safety and quality of care.

 National Quality Forum - NQF
 The quality forum is increasingly generating policy documents and doing research at the request of
 federal agencies such as AHRQ. It is also the largest cross-organizational driver of health policy in the
 quality arena. As the shift to control the quality of care continues, the NQF is well positioned to work
 across multiple organizations.


 State Safety Councils
 States are choosing unique ways to develop monitoring systems for patient safety and medical errors.
 ACEP chapters should be encouraged to participate in these efforts in their states.

                                                                                                     Page 40
Legislative and Regulatory Recommendations

Short Term

  Monitor Reporting Issues
  We must teach and guide lawmakers and regulators as they develop approaches to safety, credentialing
  and licensing, reporting, penalties, staffing ratios, and even practice standards. Because this issue is of
  such importance to the membership and the effects are likely to be very long-lasting, it is essential that
  the College participate aggressively at both the federal and state levels in the legislative and political
  processes that will define practices for years to come.


  Develop Model Legislation for Victim Compensation Methods
  The College should lead efforts to develop novel approaches to compensating victims of medical errors.
  The long term goal of promoting these approaches in the states should be considered.


Patient safety and the improvement of quality and performance in emergency medicine will drive much
change in the foreseeable future. ACEP and its members will be greatly affected by initiatives in these
areas. Therefore, we must take on roles of leadership in defining the patient safety and performance
improvement agenda for our patients, our members and for society. We must participate fully in its

To paraphrase Eldridge Cleaver, if we are not part of the solution, we are part of the problem. As the
largest emergency medicine organization, it is our responsibility to work with our colleagues in
emergency medicine to define the quality agenda for the benefit of our patients. ACEP’s mission and
values clearly note that quality patient care is a cornerstone of our beliefs. The challenge to the
organization will be to apply these beliefs to the area of patient safety and to translate them into real,
quantifiable actions.

                                                                                                       Page 41

1. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National
   Academy Press, 1999.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.
   Washington, DC: National Academy Press, 2001.

3. American College of Emergency Physicians. ACEP Mission and Values Statement. American College of
   Emergency Physicians web site. Available at: http://www.acep.org/1,483,0.html. Accessed August 30, 2001.

4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 1999 Emergency Department
   Summary. Advance data from vital and health statistics; no. 320. Hyattsville, Maryland: National Center for
   Health Statistics. 2001.

5. Quality Interagency Coordination (QuIC) Task Force Meeting, Washington DC, September 11, 2000.

6. A Call to Action, A Consensus Statement from the National Quality Forum, Kenneth W. Kizer, Medscape,
   March 21, 2001.

7. Making Health Care Safer, A Critical Analysis of Patient Safety Practices, Evidence Report/Technology
   Assessment, No. 43, AHRQ, Washington DC, 2001.

8. Leapfrog Group. 2000. “Leapfrog Patient Safety Standards: The Potential Benefit of Universal Adoption.”
   Online. Available at http://www.leapfroggroup.org.

9. Anesthesia Patient Safety Foundation. http://www.apsf.org

10. Emergency Medical Treatment and Active Labor Act (EMTALA) (Examination and treatment for
    emergency medical conditions and women in labor). 42 USC 1395 dd (1986), as amended by the Omnibus
    Budget Reconciliation Acts (OBRA) of 1987, 1989, and 1990.

11. http://www.omhrc.gov/clas/ds.htm

12. The Emergency Department Role in Patient Safety Initiatives: The Need for Collaboration. Presented by
    Susan Nedza, MD, MBA, FACEP, at the National Summit on Medical Errors and Patient Safety Research,
    QuIC, Washington DC, September 11, 2000.

13. Society for Healthcare Epidemiology of America's textbook titled A Practical Handbook for Hospital
    Epidemiologists, edited by Loreen Herwaldt and Michael Decker (Thorofare, NJ: SLACK Incorporated,
    1998), specifically Chapter 13 by R. Michael Massanari, Kim Wilkerson, and Sheri Swartzendruber on
    designing surveillance for noninfectious outcomes of medical care.

14. http://www.hhs.gov/news/press/2001pres/20010423.html

15. National Academy for State Health Policy. http://www.nashp.org/progs/prog0020.htm

16. Joint Commission on Accreditation of Healthcare Organizations. Revisions to Joint Commission Standards
    in Support of Patient Safety and Medical/Health Care Error Reduction.

                                                                                                     Page 42
17. Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

18. Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients: results from
    the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-84.

19. East TD, Morris AH, Wallace CJ, et al. A strategy for development of computerized critical care decision
    support systems. Int J Clin Monit Comput 1991-92;8(4):263-9.

20. Barnett O: Computers in medicine. JAMA 1990;263:2631-2633.

21. Cordell WH, Overhage JM, Waeckerle JF. Strategies for improving information management in emergency
    medicine to meet clinical, research, and administrative needs. The Information Management Work Group.
    Ann Emerg Med 1998;31:172-8.

22. Alper PR: The doctor-patient divide. The Wall Street Journal, October 2, 1992.

23. National Information Infrastructure Health Information Network. The essential medical data set (EMDS),
    version 2.0. 1997.

24. National Center for Injury Prevention and Control. Data elements for emergency department systems,
    release 1.0. Atlanta, GA: Centers for Disease Control and Prevention, 1997.

25. Barthell EN. Essential Medical Data Set/Data Elements for Emergency Department Systems
    EMDS/DEEDS, http://www.infinityhealthcare.com/emds, January 13, 1997.

26. Chisholm DC, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: Are
    emergency physicians “interrupt driven” and “multitasking?” Acad Emer Med, 2000;11:1239-1243.

27. Gold DR, Rogacz S, Bock N, et al. Rotating shift work, sleep, and accidents related to sleepiness in hospital
    nurses. Am J Public Health, 1992 Jul;82 (7):1011-4.

28. Price WJ, Holley DC. Shiftwork and safety in aviation. Occup Med, 1990; 5(2):243-77.

29. National Patient Safety Foundation. http://www.npsf.org

30. National Quality Forum. http://www.qualityforum.org

                                                                                                        Page 43
                                                               Recommendations Matrix
                                                               Patient Safety Task Force
                                    Short Term                                    Intermediate                                  Long Term

I.   Education         Safety site on ACEPs website                Patient Safety News letter                Independent EMPSF
                       Website links                               ED meeting courses (block time)           Specific quality and patient safety meeting
                       ACEP news article - low hanging fruit                                                 Separate website for patient safety
                       Educational meeting courses (block)

II. Best Practices     Define Best Practices                       Recognize Best Practices                  Disseminate Best Practices

III. Policy            Policy on Reporting Medical Errors          Monitor member activity                   Collect data on medical errors
                       Talking Points on Patient Safety            Serve as a clearinghouse for testimony
                       Summit on Patient Safety with NPSF
                       Develop Sentinel Event List for EM
                       Clinical Policy on Safe Practices
                       -- at the Time of Transfer of Care
                       -- related to Patients Awaiting Admission

IV. Operations         Quality Steering Group                                                                Independent Emergency Medicine Patient Safety
                                                                                                              Foundation (EMPSF)

V. Research            Endorse SAEM research documents             Partner with SAEM to encourage research   ACEP seeks grants to do Patient Safety
                       Monitor funds and grants available          EMF- designated area of research

VI. Liaison            NPSF                                        State Safety Councils
    Relationships      IHI

VII. Legislative and   Monitor reporting issues                    Develop model legislation

                                                                                                                                                 Page 44
                             American College of Emergency Physicians
                               Patient Safety Task Force Members

Susan Nedza, MD, MBA, FACEP, Chair

J. Brian Hancock, MD, FACEP, ACEP Board Liaison

Bruce S. Auerbach, MD, FACEP
James J. Augustine, MD, FACEP
Louis S. Binder, MD, JD, FACEP
Stephen V. Cantrill, MD, FACEP
James A. Espinosa, MD, FACEP
Tony Joseph, MD, FACEP
Brian F. Keaton, MD, FACEP
John R. Lumpkin, MD, FACEP
Vincent Markovchick, MD, FACEP
David L. Meyers, MD, FACEP
Daniel Pollock, MD
Matt Rice, MD, JD, FACEP
Robert L. Wears, MD, MS, FACEP
Robert A. Czincila, DO, Emergency Medicine Residents Association Representative
Linda F. Yee, RN, MSN, CEN, Emergency Nurses Association Representative

ACEP Committees assigned to the task force:

 Academic Affairs Committee
 Clinical Policies Committee
 Emergency Medicine Practice Committee
 EMS Committee
 Ethics Committee
 Medical Legal Committee
 Pediatric Emergency Medicine Committee
 Public Health Committee
 Public Relations Committee
 State Legislative/Regulatory Committee
 Trauma Care & Injury Control Committee
 Violence Prevention Committee
 Well-being Committee

Marilyn Bromley, ACEP Staff Liaison

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