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Experience in adverse events detection in an emergency department: Nature of events
Author(s) -
Hendrie James,
Sammartino Luke,
Silvapulle Mervyn J,
Braitberg George
Publication year - 2007
Publication title -
emergency medicine australasia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.602
H-Index - 52
eISSN - 1742-6723
pISSN - 1742-6731
DOI - 10.1111/j.1742-6723.2006.00897.x
Subject(s) - medicine , seriousness , emergency department , drug reaction , adverse effect , emergency medicine , drug , pediatrics , psychiatry , political science , law
Objective: The study was performed to determine the nature of adverse events in an ED. Methods: The methodology has been described in the accompanying paper. Two by two tables were analysed using the two‐tailed Fisher’s exact test. A P ‐value of ≤0.05 was considered significant. Statistical analysis was performed using MINITAB. Results: One hundred and ninety‐four events were detected, from a sample of 3222 patients. Except where specified, events with management causation ≤3 were excluded. This excluded 24 events (12.4%) leaving 170 for analysis. Errors of commission occurred in 55% and omission in 45%. Errors of commission were significantly associated with prior events, errors of omission with ED events ( P ≤ 0.0001, respectively). The most common cause of events was drug reactions. 1.35% had a Naranjo score ≥ 1, 0.54% ≥ 4. Prior events were significantly associated with adverse drug reactions ( P ≤ 0.0001). Drug reactions were associated with a lower preventability score ( P ≤ 0.0001). Diagnostic issues were present in 1.2%. All three categories, that is diagnosis not considered, diagnosis within the differential and seriousness not appreciated were associated preventability ≥4 ( P ≤ 0.0001, P ≤ 0.02 and P ≤ 0.004, respectively). Diagnostic problems were significantly associated with ED events ( P ≤ 0.0001). Conclusion: In conclusion, the data demonstrate that events fall into two sets: prior events which are associated with errors of commission, drug reactions and lower preventability; and ED events which are associated with errors of omission, diagnostic issues and high preventability.