Experience in adverse events detection in an emergency department: incidence and outcome of events. 2007

James Hendrie, and Luke Sammartino, and Mervyn J Silvapulle, and George Braitberg
Emergency Department, Austin Health, Victoria, Australia. james.hendrie@austin.org.au

OBJECTIVE The study was performed to determine the incidence, outcome and preventability of adverse events (AE) in an ED. METHODS The Quality in Australian Health Care Study methodology, modified to the ED, was utilized. Case histories of patients presenting to a tertiary hospital ED were screened for events. Events detected were classified, using a 104-item data collection instrument, entered on Excel and analysed statistically using MINITAB. RESULTS A total of 5345 patients presented during the study period. Three thousand three hundred and thirty-two patients completed full evaluation and comprised the study population. One hundred and ninety-four events were detected. Except where specified, events with management causation < or = 3 were excluded. This excluded 24 events (12.4%) leaving 170 for analysis. Of patients suffering an event, 53.5% occurred prior ED attendance, 41.7% of AE occurred within the ED, and 4.7% had contributions from both. The overall event rate, detected by the screening process, was 5.1%, with an incident rate of 1.98% and AE rate of 3.12%. The ED AE rate was 1.0%. If only those with management causation = 1 are excluded, then the overall event rate was 5.52%, with an AE rate of 3.33%. Fifty-five per cent of events were judged to be preventable (preventability score > or = 3). Events resulting in death and disability were more likely to be preventable (P < or = 0.04). CONCLUSIONS In conclusion, the Quality in Australian Health Care Study methodology has been utilized to provide data on incidents and AE in an ED.

UI MeSH Term Description Entries
D008297 Male Males
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D002648 Child A person 6 to 12 years of age. An individual 2 to 5 years old is CHILD, PRESCHOOL. Children
D002675 Child, Preschool A child between the ages of 2 and 5. Children, Preschool,Preschool Child,Preschool Children
D004636 Emergency Service, Hospital Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient. Emergency Outpatient Unit,Emergency Services Utilization,Hospital Emergency Room,Hospital Emergency Service,Hospital Emergency Services Utilization,Accident and Emergency Department,Emergency Departments,Emergency Hospital Service,Emergency Room,Emergency Units,Emergency Ward,Hospital Service Emergency,Service, Hospital Emergency,Department, Emergency,Departments, Emergency,Emergencies, Hospital Service,Emergency Department,Emergency Hospital Services,Emergency Outpatient Units,Emergency Room, Hospital,Emergency Rooms,Emergency Rooms, Hospital,Emergency Services, Hospital,Emergency Unit,Emergency Wards,Emergency, Hospital Service,Hospital Emergency Rooms,Hospital Emergency Services,Hospital Service Emergencies,Hospital Service, Emergency,Hospital Services, Emergency,Outpatient Unit, Emergency,Outpatient Units, Emergency,Room, Emergency,Room, Hospital Emergency,Rooms, Emergency,Rooms, Hospital Emergency,Service Emergencies, Hospital,Service Emergency, Hospital,Service, Emergency Hospital,Services Utilization, Emergency,Services Utilizations, Emergency,Services, Emergency Hospital,Services, Hospital Emergency,Unit, Emergency,Unit, Emergency Outpatient,Units, Emergency,Units, Emergency Outpatient,Utilization, Emergency Services,Ward, Emergency,Wards, Emergency
D005260 Female Females
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000293 Adolescent A person 13 to 18 years of age. Adolescence,Youth,Adolescents,Adolescents, Female,Adolescents, Male,Teenagers,Teens,Adolescent, Female,Adolescent, Male,Female Adolescent,Female Adolescents,Male Adolescent,Male Adolescents,Teen,Teenager,Youths
D000368 Aged A person 65 years of age or older. For a person older than 79 years, AGED, 80 AND OVER is available. Elderly
D000369 Aged, 80 and over Persons 80 years of age and older. Oldest Old

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