Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care

Presented at the annual meeting of the Society for Academic Emergency Medicine, June 2008, Washington, DC.

Received 27 December 2007; received in revised form 3 April 2008 and 29 April 2008; accepted 5 May 2008. published online 16 June 2008.

Refers to article:

Beyond “Communication Failure” , 26 August 2008
Emily S. Patterson, Robert L. Wears
Annals of Emergency Medicine
June 2009 (Vol. 53, Issue 6, Pages 711-712)
Full Text | Full-Text PDF (116 KB)

Study objective

We identify, describe, and categorize vulnerabilities in emergency department (ED) to internal medicine patient transfers.

Methods

We surveyed all emergency medicine house staff, emergency physician assistants, internal medicine house staff and hospitalists at an urban, academic medical center. Respondents were asked to describe any adverse events occurring because of inadequate communication between emergency medicine and the admitting physician. We analyzed the open-ended responses with standard qualitative analysis techniques.

Results

Of 139 of 264 survey respondents (53%), 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after ED to inpatient transfer. These 40 respondents described 36 specific incidents of errors in diagnosis (N=13), treatment (N=14), and disposition (N=13), after which patients experienced harm or a near miss event. Six patients required an upgrade in care from the floor to the ICU. Although we asked respondents to describe communication failures, analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; “boarding” in the ED; and ambiguous responsibility for sign-out or follow-up.

Conclusion

The transfer of a patient from the ED to internal medicine can be associated with adverse events. Specific vulnerable areas include communication, environment, workload, information technology, patient flow, and assignment of responsibility. Systems-based interventions could ameliorate many of these and potentially improve patient safety.

a Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, CT

b Hospitalist Service, Yale–New Haven Hospital, New Haven, CT

c The Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT

d Section of Emergency Medicine, Department of Surgery, Yale University School of Medicine, New Haven, CT

e Section of Geriatrics, Department of Medicine, Yale University School of Medicine, New Haven, CT

f The Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA

g The Department of Medicine, Harvard Medical School, Boston, MA

Address for reprints: Leora Horwitz, MD, MHS, Yale–New Haven Hospital, 789 Howard Ave, New Haven, CT 06510; 203-688-5678, fax 203-688-5571

Provide feedback on this article at the journal's Web site, www.annemergmed.com.

Supervising editor: Robert L. Wears, MD, MS

Author contributions: LIH, JDS, NRS, RGK, and GYJ conceived the study and designed the survey. NRS, RGK, and GYJ supervised data collection. LIH was responsible for data management, including quality control. LIH, TM, and GYJ coded the data, and JDS, NRS, and RGK participated in the qualitative analysis. LIH drafted the article, and all authors contributed substantially to its revision. LIH 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. Dr. Horwitz was a VA Special Fellow and was supported by the Department of Veterans Affairs during part of the time this study was conducted. Dr. Horwitz is now supported by Yale–New Haven Hospital. Neither the Department of Veterans Affairs nor Yale–New Haven Hospital had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the article.

Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com.

Publication date: Available online June 16, 2008.

PII: S0196-0644(08)00795-6

doi:10.1016/j.annemergmed.2008.05.007

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