Patient safety has been one of the most important medical issues in the past few years, after the release of the Institute of Medicine\’s quality of care initiative, “To Err is Human: Building a Safer Health System”. Although a few reports related to emergency department (ED) adverse events/medical error have been published, relatively little is well known about the cause of ED adverse events/errors. A few studies of medical malpractice in ED cases were informative, but reviewing medical adverse events had the shortcomings of outcome biases and retrospective biases in retrospective studies, especially in closed lawsuit cases, in which many biased purposes were present. Therefore, many reports called for more data to be published about medical adverse events/error for further analysis of their patterns and causes. Our previous study showed that many of these adverse events were due to inadequacies in the basic management process (history taking, physical examinations, laboratory and radiological examinations, and observation). Therefore, our main purposes are to explore clinically significant adverse events (CSAEs), with an emphasis on those related to physicians\’ factors, through the analysis of the basic management process and provide evidences for these insufficiencies in discharged patients of emergency medicine (EM).
In this brompheniramine maleate study, the CSAEs rate was 1.21% (1,230/101, 402, 95% CI=10.28% – 13.92%) and CSAEs rate related to physicians\’ factors was 0.7% (722/101,402, 95% CI 0.69% – 0.75%) in the discharged patients of EM. Most CSAEs related to physicians\’ factors (98.9%) had inadequacies in the basic management process and only a minority (1.1%) were determined to be caused purely by “judgment defects”. Inadequacies of history taking (34.2%, 247/722) and the lack of observation of high-risk clinical conditions and treatment response in high-risk conditions (42.4%, 306/722), were the most common. In this study, evidence present in the basic management process to support adverse events revealed clusters of common causes:
Our results had several points agreeing with or in support of previous studies. Firstly, our providing data of adverse events/errors is an act advocated by the EM. Providing more data relating to the medical error is an important issue in the EM. Our data included a rate of CSAEs (also those related to physicians\’ factors), patterns of inadequacies, and evidence (detailed analysis) of these inadequacies. There has been scarce data related to understanding and examining medical errors in the emergency medicine. Fordyce et al reported the error rate was 18/100 registered patients and the significant adverse event rate was 0.36/100 registered patients in the ED patients. Ninety-eight percent of errors in the ED do not result in adverse outcomes. Forster et al also reported a 6% adverse event rate in ED discharged patients, but many of these were mild events.
Secondly, our results re-emphasized the importance of the basic management process in preventing the adverse events/errors. In our results, a high proportion of CSAEs related to physicians\’ factors had inadequacies in history taking and testing. Previous studies have shown many adverse events or errors occurred under the situations similar to our results: oversimplified history taking and physical examinations, inadequate laboratory testing and radiological examinations, the incorrect reading of radiological films or breakdown in diagnostic processes (history taking, physical exams, ordering tests, and producing a follow-up plan). Additionally, one of the most notable findings with our results was the high proportion of the lack of observation of patients with persistent abdominal pain in CSAEs related to physician factors (111/722). Most of these cases were given diagnoses of minor diseases (gastritis, peptic ulcer, dyspepsia, irritable bowel syndrome, acute gastroenteritis and so on). Under these “definite diagnoses”, premature closure and early discharge were the rule. This inadequacy calls for the necessity of observation of many patients. Our previous study also showed cuticle early discharging of high-risk patients without observation or re-evaluation was a factor causing adverse events. Before discharging a patient, EPs have to make sure of the improvement of the patient symptoms. A serial follow-up is frequently necessary in many ED clinical conditions to make sure of the response and is also an important part in the ED practice which has a high uncertainty.