Medical errors in emergency departments

Most of us would dread ever having to pay a visit to our local hospital emergency department (ED). This really is the "business end" of the health service and is by its very nature, usually not a happy place.

A&Es are the great equaliser of the Irish health service, with both public and private patients sharing often less then optimal facilities.

For various reasons which have been enumerated ad nauseam in most commentaries on EDs, their understandably serious and often chaotic atmosphere is worsened by long waits, discomfort, overcrowding, pressure, inappropriate use and often, lack of proper hygiene.

It's a sobering fact that 3,300 patients attend EDs in 35 hospitals around the country each day; over 1.2 million attendances every year.

While some slight improvements have been made in ED services, they remain a serious pressure point in our health system.

All human life is indeed contained within the A&E and while emergency staff often provide heroic service under extreme circumstances, human error can be prevalent in these situations.

In this context, some new research may add to any worries we might have about being a future patient in our emergency department system.

An analysis carried out by the Clinical Indemnity Scheme (CIS) has concluded that the hospital ED is the birthplace of many medical negligence claims, and that many of these claims relate to misdiagnosis.

The CIS, which operates under the State Claims Agency, indemnifies hospitals and their medical staff against negligence claims arising from "adverse incidents"; in other words, when things go wrong, as they often do, sometimes due to medical or diagnostic error.

It points out that emergency medicine is responsible for 15% of all medical negligence claims.

The CIS looked at closed (that is, fully processed) medical negligence claims for the specialty of emergency medicine that it handled from around 2002 to the end of 2008. There were 203 such cases.

It found that 53.6% of the cases did not proceed to a full claim and 25% were settled out of court.

Of the settled claims, 59% were diagnosis-related, with 94% of these categorised as a result of failure to diagnose.

A further analysis of these diagnoses reveals that 74.2% were fracture and musculo-skeletal injury-related.

Worryingly perhaps, further analysis revealed that the senior house officer (SHO) grade of doctor was most likely to be involved in a claim versus registrar at 14% and consultant at 8%. The SHO is, in the hospital hierarchy, the lowest grade of junior doctor other than the intern.

The CIS points out that it is the SHO grade that is also the grade that evaluates and treats the majority of patients presenting to emergency departments. This is a trend not confined to Ireland, as it has also been found in international studies.

The CIS found that 57% of the errors concerned in its study had a primary root cause specifically related to staff skill/knowledge/competence. Experts reviewing the cases concerned found that fractures may have been visible on radiographs (x-rays) but were missed by the treating doctor, "making the claim indefensible and resulting in out-of-court settlements."

The CIS says given that the majority of ED attendances in Ireland are seen by junior doctors, it is important to have adequate training and supervision with regard to x-ray interpretation, and follow-up with more senior colleagues encouraged.

The CIS says an increased emphasis on ongoing education and feedback regarding accurate radiological interpretation is essential for all ED training rotations.

It points out that recent IT innovations "allow doctors to routinely review a soft copy of an x-ray on work stations within the department almost immediately after the x-ray has been taken."

However,  the CIS notes that this technology is not available in every emergency department and for departments that do not have this type of technology, other processes and specialised training for non-radiology emergency department doctors remains essential.

It says: "A standardised reporting system is crucial so that missed fractures identified by other personnel, such as radiology consultants, are immediately alerted to the relevant emergency department physician for immediate action and follow-up."

The report also says a comprehensive patient call-back system with definitive roles and responsibilities to ensure patients are not lost in the system is also required.

"Ongoing communication between radiology and emergency departments is essential to ensure patient safety."

The report also points to the need for multidisciplinary team reviews of errors.

The report also stresses that communication with the patient about the difficulties interpreting radiographs is also important, as it was found that patients were less likely to be upset if they were called back if they received adequate communication and information during the initial consultation.

The report concludes that interpretation of x-rays is a skill that requires ongoing education and training throughout training rotations, not just on orientation.

Despite the findings, it should be stressed that the number of errors which led to claims being made were extremely small compared to the one million plus consultations in A&E departments each year.

This is a point is made by Mr Fergal Hickey of the Irish Association for Emergency Medicine (IAEM), which represents consultants in the specialty in Ireland.

He points out that that the number of claims being dealt with was 203 over a number of years (when there were in excess of one million attendances per year at EDs), of which 53% did not proceed to a full claim.

Mr Hickey told it was actually surprising that the number of errors was not higher in the context of the current problems with staffing, resourcing and infrastructure in emergency departments.

He cllaims emergency staff in hospitals are constantly "putting out fires" in extremely difficult working conditions.

He said he would not disagree with the report's recommendation that all EDs should have systems in place to ensure that x-rays are accurately interpreted and where , if there is a discrepancy between the assessment of the treating doctor and the radiology department, ther should be good liaison to ensure that these discrepancies are followed-up as quickly as possible.

Mr Hickey noted that the report referred to the lack of PACS computer systems in most hospitals in Ireland. Such systems can allow doctors to routinely review a soft copy of the x-ray with in the ED almost immediately after they have been taken.

He said having such systems in place would reduce the potential for misdiagnoses.

Mr Hickey added that other factors also had to be take into account including the severe overcrowding in many EDs, often necessitating examinations having to take place in sub-optimal surroundings, such as hospital corridors.

Referring to the report's concerns about supervision of junior doctors and the fact that SHOs were commonly involved in evaluation and treatment, he said much of this problem had its roots in the lack of consultant emergency physicians.

"There is a serious shortage of consultants in emergency medicine and that is one of the reasons why so much decision-making is done by junior doctors."

Mr Hickey said the new consultant contract had provided for longer hours for consultants, but many ED consultants were already working these additional hours in any case.

He said having more consultants available in EDs outside normal office hours was contingent on more consultant posts being filled.

He said the IAEM had also called for a new grade of doctor, below consultant but more senior than a junior hospital doctor to be appointed to EDs, but the medical representative organisations had opposed this.

According to Mr Hickey, while he would would agree with the report's redommendation on having systems in place to minimise diecrepancies and errors, the problems outlined had their roots in current deficiencies in resourcing, staffing and infrastucture.

These were issues that needed to be dealt with by the HSE, he said.





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