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N ational C oroners I nformation S ystem: A valuable source of lessons for emergency medicine
Author(s) -
Curran Justin,
McD Taylor David
Publication year - 2012
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.1742-6723.2012.01575.x
Subject(s) - medicine , referral , emergency department , documentation , theme (computing) , family medicine , medical emergency , nursing , computer science , programming language , operating system
Objective To interrogate the N ational C oroners I nformation S ystem ( NCIS ) to determine the recurrent themes among coroners’ recommendations that aimed to increase the safety of ED care. Methods This was a retrospective analysis of NCIS closed cases, from Q ueensland, N ew S outh W ales, T asmania, V ictoria, A ustralian C apital T erritory, S outh A ustralia and N orth T erritory, entered since its inception in 2000. The keyword ‘emergency department’ returned 1645 cases, of which 180 were found to be relevant. The primary outcomes were the number and nature of cases where recommendations for improvements in ED care had been made and the recurrent themes of these recommendations that could inform education initiatives. Results Of the 180 cases, 108 (60.0%) were of deceased men and subject age ranged from 2 days to 91 years. The commonest causes of death were trauma (26.7%), infection (24.4%), cardiac events (15.0%) and poisoning (8.9%). No coronial recommendations were required in 19 cases. For the remainder, recommendation themes related to issues of risk management/medico‐legal, diagnostic/therapeutic error, education, documentation/communication and re‐presentation. The themes associated with the different doctor designations (consultant, registrar, resident/intern) were similar, although registrars and residents/interns tended towards more diagnostic/therapeutic errors. The themes associated with hospital type (referral, urban, regional/rural) were also similar. Although theme analysis is important, some individual cases were particularly instructive. Conclusion The NCIS data theme analysis indentifies important high‐risk patients and presenting complaints. These should be incorporated into emergency physician training. EDs should review the coronial recommendations to ensure that, where possible, they have been adopted.