Characteristics of Patient Care Management Problems Identified in Emergency Department Morbidity and Mortality Investigations During 15 Years
Received 18 November 2006; received in revised form 8 March 2007, 21 May 2007 and 14 June 2007; accepted 25 June 2007. published online 15 October 2007.
Refers to article:
Thick Versus Thin: Description Versus Classification in Learning From Case Reviews
, 15 October 2007
Robert L. Wears, Ben-Tzion Karsh
Annals of Emergency Medicine
March 2008 (Vol. 51, Issue 3, Pages 262-264) Full Text |
Full-Text PDF (78 KB)
Study objective
We describe cases referred for physician review because of concern about quality of patient care and identify factors that contributed to patient care management problems.
Methods
We performed a retrospective review of 636 cases investigated by an emergency department physician review committee at an urban public teaching hospital over a 15-year period. At referral, cases were initially investigated and analyzed, and specific patient care management problems were noted. Two independent physicians subsequently classified problems into 1 or more of 4 major categories according to the phase of work in which each occurred (diagnosis, treatment, disposition, and public health) and identified contributing factors that likely affected outcome (patient factors, triage, clinical tasks, teamwork, and system). Primary outcome measures were death and disability. Secondary outcome measures included specific life-threatening events and adverse events. Patient outcomes were compared with the expected outcome with ideal care and the likely outcome of no care.
Results
Physician reviewers identified multiple problems and contributing factors in the majority of cases (92%). The diagnostic process was the leading phase of work in which problems were observed (71%). Three leading contributing factors were identified: clinical tasks (99%), patient factors (61%), and teamwork (61%). Despite imperfections in care, half of all patients received some benefit from their medical care compared with the likely outcome with no care.
Conclusion
These reviews suggest that physicians would be especially interested in strategies to improve the diagnostic process and clinical tasks, address patient factors, and develop more effective medical teams. Our investigation allowed us to demonstrate the practical application of a framework for case analysis. We discuss the limitations of retrospective cases analyses and recommend future directions in safety research.
Department of Emergency Medicine, Cook County Hospital, Rush Medical School, Chicago, IL.
Address for reprints: Karen Cosby, MD, Department of Emergency Medicine, Cook County Hospital (Stroger), 10th floor Administration Building, 1900 W Polk St, Chicago, IL 60612; 312-864-1986 or 312-864-0060, fax 312-864-9656
Supervising editor: Robert L. Wears, MD, MS
Author contributions: KSC and RR conceived the study and obtained funding. KSC, RR, JS, and RDS designed the study. KSC, LP, CR, JS, S Sherman, IN, EC, ML, and S Schabowski were responsible for data acquisition. KSC, RR, IA, and RDS analyzed and interpreted the data. KSC and RR drafted the article and all authors contributed substantially to its revision. KSC, RR, IA, and RDS were responsible for statistical analysis. RR, LP, CR, JS, S Sherman, IN, EC, ML, S Schabowski, IA, and RDS provided administrative, technical, or material support. KSC and RR were responsible for overall study supervision. KSC and RR had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. KSC takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was funded in part by the Agency for Healthcare Research and Quality, grant number 5 P20 HS011552, and the Department of Emergency Medicine, Cook County Hospital (Stroger).
Publication date: Available online October 15, 2007.
ABSTRACT