Identification of Factors Affecting Patient Safety in the Emergency Department: A Retrospective Study
Correspondence Address :
Dr. Sultan Alamri,
Assistant Professor, Department of Radiological Sciences, Taif University, Taif, Makkah, Saudi Arabia.
E-mail: dr.sultan.alamri@gmail.com
Introduction: Emergency Departments (EDs) have been described as complex, dynamic and at high risk for medical errors. Factors affecting the risk of medical error in the ED are related to communication, triage and medication management and upto 3% of all medical errors in hospitals take place in the ED.
Aim: To identify the factors affecting patients’ safety in the EDs of two major hospitals in Taif city based on Occurrence Variance Reporting (OVR).
Materials and Methods: The present study was a cross-sectional retrospective study which was conducted from January 2018 to October 2020 at King Abdul-Aziz Specialist Hospital (KAASH) and from October 2018 to October 2020 at King Faisal Medical Complex (KFMC) in Taif city, Makkah, Saudi Arabia. The OVR data included six variables including category of OVR, name of hospital, year of OVR, type of report, who made the OVR and action taken by the hospitals, and was analysed using International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS).
Results: This study found that 3,632 OVR reports were collected. Nearly two-thirds of all OVRs were associated with nursing care management issues, followed by identification/document/consent issues (9.4%), medical equipment issues (5.5%), housekeeping issues (0.2%) and laundry service (0.1%) representing the lowest frequency of OVR. Unsafe conditions accounted for 75.17% (2,730) of all OVR reports and only 24.83% (902) were incident reports. Staff nurses reported a majority of reports (89.5%), with 10.5% of OVRs reported by other healthcare workers. The primary actions taken by the hospitals in response to these reports were detection (72.3%) and prevention (17.4%), while only 10.3% was corrected.
Conclusion: Patient safety is the primary challenge faced by healthcare providers at hospitals. Thus, OVR is a very important tool in order to avoid errors and limit harms ensuring healthcare quality and safety delivery.
Medical error, Occurrence variance reporting, Risk
The EDs provide immediate access to medical care. However, there is a risk of exposure to medical error caused by mistakes made by healthcare providers. These unintended adverse events can lead to poor outcomes including disability, or even death (1). The number of patients who utilised the ED in Saudi Arabia from 2011 to 2015 was estimated to be 102.2 million (2). Medical actions in the ED can be non urgent or urgent in nature. Incomplete information on the patient’s condition may lead to the provision of unnecessary or inappropriate interventions. In contrast, hospitals that have instituted constant rounds have demonstrated higher levels of refinement and optimisation of their medical care (3).
The World Health Organisation (WHO) defines patient safety as “the absence of preventable harm to a patient during the process of healthcare” and established global norms, and evidence-based policies to guarantee excellence in patient’s safety (4). In the United States 100,000 patients lost their lives due to medical errors every year (5). The term “medical error” is widely used in patient safety literature to describe a failure that occurs in the processes of healthcare but does not necessarily include harm (6). The OVR is essential for ensuring patient and staff safety, quality of care, and risk management. Occurrence reports are used to report events that may have risk management considerations and may require further follow-up by other departments (7). A successful OVR system is one in which 100% of the outcomes of incidents are reported to the risk manager as the purpose of OVR is to provide complete facts regarding any incidents (8). Therefore, this study aimed to identify the factors affecting patient safety in the EDs based on an assessment of OVRs at KAASH and KFMC in Taif city, Saudi Arabia.
A cross-sectional retrospective study was conducted from January 2018-October 2020 at KAASH and from October 2018-October 2020 at KFMC in Taif city. The analysis of the study was done from December 2020-January 2021. The proposal for this study was approved by the Directorate of Health Affairs-Taif (IRB Registration Number with KACST, KSA: HAP-02-T-067, approval number 424 on 10/9/2020).
Data were collected from the quality management and patient safety departments at both hospitals using a checklist of the monthly OVRs between October 2020 and December 2020. The OVR data included six variables: category of OVR [Appendix A], name of hospital, year of OVR (including 2018, 2019, and 2020), type of report including incident, near miss, and unsafe condition [Appendix B], who made the OVR (including nurses and other healthcare workers), and action taken by the hospitals (including correction, detection, and prevention).
Statistical Analysis
After reviewing and coding the collected data, it was analysed using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics such as frequency and percentage were used for qualitative variables and the Chi-square test was used to compare dependent and independent variables.
During the study period, 3,632 OVR reports were collected. Nearly two-thirds of all OVRs were associated with nursing care management issues, followed by ID/document/consent issues (9.4%) and medical equipment issues (5.5%). Housekeeping (0.2%) and laundry service (0.1%) issues represented the lowest proportion of OVRs (Table/Fig 1). Unsafe conditions accounted for 75.17% of these reports (2730), while only 24.83% were incident reports (902). Only four reports were in the near miss category, which represented a negligible value, so these reports were added to the unsafe condition reports (Table/Fig 2). Staff nurses reported the majority of OVRs (n=3251, 89.5%) and the remaining reports were by other healthcare workers (n=381, 10.5%). The primary action taken in response to these reports was detection (n=2626, 72.3%), followed by prevention (n=633, 17.4%) and correction (n=373, 10.3%).
There were differences in OVR reporting between KAASH and KFMC from 2018 to 2020. In 2018, of the total 1,337 reports that were conducted, including both unsafe conditions and incidents, 1,235 reports were from KAASH, while only 102 reports were from KFMC. In 2019, 1,683 reports were conducted including both unsafe conditions and incidents, with 1,063 reports occurring at KAASH and 620 reports occurring at KFMC. In 2020, a total of only 612 reports were conducted including both unsafe conditions and incidents, 388 of which occurred at KAASH and 224 of which occurred at KFMC (Table/Fig 2).
The number of OVR reports conducted differed between hospitals during the study period. Of the total of 3,632 reports conducted in both hospitals from 2018 to 2020, 2,686 (73.9%) were conducted at KAASH, while only 946 (26.1%) were conducted at KFMC. There was a statistically significant difference (p-value <0.001) between hospitals in the number of OVR reports (Table/Fig 3).
This study aimed to identify the factors affecting patient safety in the EDs at KAASH and KFMC based on their OVRs. It was determined that 3,632 OVR reports were conducted during the study period. A similar Saudi study conducted in Riyadh found that a total of 2,362 OVRs were reported to the quality management department in 2020 alone (9). The number of OVRs reported at the Taif hospitals included in the present study was significantly lower. This indicates increased OVR reporting in the Riyadh hospitals. A possible explanation for this might be the application of effective educational programmes in Riyadh hospitals that increased the general awareness of staff with the OVR database and its importance to the hospital, staff, and patient safety (9). Another possible explanation is that hospital policies have been modified, leading to a non-punitive culture surrounding medical errors (10).
There were 21 OVR categories found, all of them affecting patient safety in the ED to a varying degree. The most common OVR type was nursing care management issues (60.4%), followed by ID\document\consent issues (9.4%). Housekeeping issues (0.2%) and laundry service (0.1%) represented the least frequent OVR types. A study performed in Turkey in 2020 found that the types and percentage of errors in the ED varied. For example, procedural errors accounted for 38% of all errors, medication errors for 16%, documentation errors for 13%, and communication for 12% (11). This study, in contrast, found that procedural and medication errors each accounted for only 0.4% of all errors, with documentation errors accounting for 9.4% and communication errors accounting for 1.4%. Moreover, it has been shown that up to 90% of nurses can expose to violence (security-related issue) (12). In the present study, all security-related issues accounted for only 2.8%. This indicates that the factors affecting patient safety in the ED are different from one country to another. In agreement with the present study, in which issues relating to nursing care management accounted for the majority of OVRs reported (n=2194), a previous Saudi study performed at Al Qassim at King Saud Hospital in 2014 demonstrated that the majority of OVR types were due to nursing care management (n=389) (7).
In assessing the medical staff who report OVR events, the current study indicated that the majority of these reports (89.5%) were conducted by staff nurses, with only 10.5% conducted by other healthcare workers. This difference may be explained in part by the fact that there are a large number of nurses working in the hospital compared to other clinicians. In addition, reporting any incidents or medical errors is one of the important roles given to nurses. A study conducted in 2017 by the University of Cape Town found that doctors and nurses were largely unaware of the hospital’s error reporting system. This was attributed to inadequacies within the organisation, as the participants were willing to report incidents if perceived barriers were removed. This suggested an urgent need for an effective error reporting system to be implemented in the local setting and for appropriate awareness training and educational interventions to improve clinician knowledge of the system (13). A report in 2012 at King Khalid University showed that nursing staff reported about 63% of total OVR reports (9). The present study also found that nurses contribute to the majority of all OVR reports.
A previous study has revealed that fear is a key factor in not reporting medical errors (14) as they may fear punishment, legal action, or loss of employment. In addition, a lack of feedback from the quality or patient safety departments can contribute to a lack of reporting. Other barriers to reporting include personal characteristics, workload or staff shortages, nursing leadership problems, blame, lack of knowledge or skills, lack of clarity, or non compliance with policy and safety culture (15),(16). Furthermore, a study conducted in 2020 that aimed to identify major barriers to the provision of patient safety by nurses in the ED found that violent acts against ED staff constituted the main barrier to reporting (17).
The main goal of preventative action is to prevent harm, while corrective actions aim to reduce the occurrence of such errors, and detection action aim to discover the cause of potential harm to create early solution. This finding supports the effectiveness of OVR in hospitals but also demonstrates that hospital managers should devote more attention to preventing medical errors which would be beneficial to both patients and staff. A study in Saudi Arabia completed in 2014 mentioned that corrective action should be taken if the OVR information and analysis indicates that a patient was affected (7). A study conducted in 2014 discussed medical errors and suggested strategies for preventing medication errors in the ED, which included developing a safe, non-punitive approach to handling these errors (18).
Finally, the total number of reports conducted at KAASH accounted for 73.9% of all reports, while only 26.1% of all reports were conducted at KFMC. This result may indicate an improved OVR culture amongst workers at KAASH. As for the small number of reports in KFMC, there are two possible explanations. First, the Quality and Patient Safety departments at KFMC were not merged until the final quarter of 2018, which may have contributed to a reduction in the percentage of OVR reports. Second, KFMC was selected as the primary centre for Coronavirus Disease-2019 cases in the city of Taif, and consequently fewer reports were conducted during the pandemic period.
Limitation(s)
The time period considered for data collection from the two hospitals were different which may have affected the number of OVRs collected from the two hospitals.
This study aimed to identify the factors affecting patient safety in the EDs based on an assessment of OVRs. This study states that OVR is critical for achieving patient and staff safety, improving quality of care and reducing medical errors or incidents. The study found that the OVR system in the included hospitals was effective to some extent and found 21 factors that affect patient safety in the ED to different degrees. These findings highlight the need for increased awareness amongst medical staff, particularly nurses, regarding the importance of reporting all incidents.
Therefore, the study suggests that it is essential that senior management at study hospitals consider the major issues affecting the OVR system and minimise medical errors and their adverse impact on patients, staff, and hospital image. Also, hospitals should encourage the development of quality improvement plans as applicable. It is essential to provide continuous monitoring and gathering of data for analysis (monthly and quarterly) for continuous assessment. Moreover, there is a need to encourage performance by providing continuous education, rewards and commendations for the highest-reporting department. Further in-depth studies are needed to provide practical procedures to prevent or reduce the patient safety incidents.
DOI: 10.7860/JCDR/2022/52095.16062
Date of Submission: Aug 24, 2021
Date of Peer Review: Nov 30, 2021
Date of Acceptance: Dec 30, 2021
Date of Publishing: Mar 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
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• Plagiarism X-checker: Aug 25, 2021
• Manual Googling: Dec 28, 2021
• iThenticate Software: Jan 18, 2022 (7%)
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