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Design and implementation of a patient safety program for a hospital emergency department: how to do it

Tejedor Fern√°ndez M, Montero P√©rez FJ , Mi√Īarro del Moral R, Gracia Garc√≠a F, Roig Garc√≠a JJ , Garc√≠a Moyano AM

Servicio de Calidad y Documentación Clínica, Unidad de Gestión Clínica de Urgencias, Hospital Universitario Reina Sofía, Córdoba, Spain.

This paper describes the design of a patient safety program for the emergency
department of a highly complex tertiary care university hospital. The program
comprises a broad set of preventive measures for reducing the risk of identified adverse
events. An expert working group within the emergency department undertook the
following steps to create the program: 1) brainstorming to identify the potential adverse
events that occur in the emergency department as well as the errors and contributing
factors responsible for them, 2) ranking of the adverse events according to a risk priority
index by means of failure mode and effect analysis, 3) listing recommendations for risk
reduction, and 4) mapping risks onto the overall emergency care process. The working
group identified 43 adverse events, 65 types of error, 86 causes, and 207 ameliorating
actions. Each adverse event generated between 1 and 21 ameliorating actions. Problems
with the clinical care process accounted for 46.51% of the total, medication incidents for
13.95%, the diagnostic process for 6.97%, procedures for 6.97%, and infections for
2.32%. Other types of incidents accounted for 23.26% of the total. Our experience
underlines the importance of creating a patient safety culture is of great importance in
an emergency department. Such a culture can be created by first analyzing and ranking
adverse events according to level of risk and then planning ameliorating actions that
reduce risk.

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