Published: 2016. Next review: 2024.
Key learnings to inform patient safety in the emergency department
We know emergency medicine is an inherently challenging area of clinical practice. Over time, guidelines, policies and pathways have been developed and re-developed to assist emergency clinicians in the management of the entire spectrum of disease and conditions. Yet there continues to be a significant number of adverse events in emergency departments (EDs), with some being repeated many times.
Thought-based errors and cognitive bias are common in cases of patient deterioration. In the busy ED environment clinicians can be susceptible to oversights attributable to:
- pattern matching (an automated approach to interpreting information and identifying underlying patterns)
- mindset, narrow or rule-based thinking
- relying on a false hypothesis (wrong diagnosis) with insufficient evidence.
Avoiding error in the complex environment of the ED
Remembering these points will assist in delivering the right care, first time.
Atypical presentations
Many patients with potentially life-threatening conditions will present in an unusual or atypical manner and/or fail to respond to initial management for a condition as expected. It is these presentations in high-risk or complex patients that constitute a significant proportion of ED-related incidents and adverse events. Atypical presentations, or patients whose progress or response to treatment is not as expected, should trigger clinicians to consider early reassessment, investigation and consultation. This may not only manifest as deterioration, but also where there is no change in condition.
Start over
Re-assessment means starting from scratch and approaching the patient with no preconceptions. Clinicians must ignore a diagnosis that has been previously given. For example, labelling abdominal pain in an elderly person as constipation before serious surgical diagnoses have been ruled out. Clinicians should consider all information available from other sources.
Patients who represent to ED pose a higher risk
Any recent presentation to an ED, or any other medical provider for the same complaint, should flag this patient as high risk.
Recognise and respond to red flags
Red flags are indicators in the patient history or examination that alert us to potential serious diagnoses that may be mimicked by more common and less sinister conditions. Excluding potential serious diagnoses must be a conscious and active process once red flags are identified, even if the patient looks well. Keep an open mind.
It is acceptable to not know the diagnosis as clinical signs will evolve. Deliberately keeping an open mind, thinking broadly and seeking advice while addressing early stabilisation and therapy, will generally avoid the wrong clinical path. Initially undifferentiated patients constitute a high-risk group. A lack of a clear diagnosis may prevent assignment of the patient to a familiar care pathway. In this situation, re-assessment and early consultation is essential and keeping an open mind will reduce the risk of initiating inappropriate treatment.