Summary

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

Tejedor Fernández M, Montero Pérez FJ , Miñarro del Moral R, Gracia García F, Roig García JJ , García Moyano AM

Affiliation of the authors

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

DOI

Quote

Tejedor Fernández M, Montero Pérez FJ , Miñarro del Moral R, Gracia García F, Roig García JJ , García Moyano AM. Design and implementation of a patient safety program for a hospital emergency department: how to do it. Emergencias. 2013;25:218-27

Summary

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.

 

More articles by the authors

Leave a Reply

Your email address will not be published. Required fields are marked *