The most important take away point from this WSJ article “Hospitals Overhaul ER’s to Reduce Mistakes” is communication. The article states that most errors in judgment involve missing pieces of critical data or information that one team member may be aware of and assume that others know.
In an ideal world, the best model for history taking would be by the physician-nurse team on arrival so that both have the same information from the start. This can be very challenging in a busy environment with many patient care priorities. It can be nearly impossible to see every patient as soon as they arrive and some form of triage must be used to identify the sickest patients. In my busy ED, our median door to provider time is less than 20 minutes. The quicker the provider assesses the patient, the sooner treatment can start and you can identify those most at risk to decompensate.
I also think a time-out or a “huddle” is a good practice yet again, the environment makes this challenging. We do this with psychiatric patients in my ED as most of the decisions made in these cases are based on statements and history by many different people. There is greater risk for someone to have information that others may not be aware of. The officers that bring in the suicidal patient will have information from the scene. The family that arrives much later may have other important information to add after the provider has already seen the patient. The nurse, the physician and the psychiatric counselor interview the patient. The patient may make a comment to the ER tech that is sitting at the bedside. The huddle brings everyone onto the same page at the time the decision to admit or discharge is made.
I find it interesting that the malpractice provider quoted in the article advises that all chest pain patients should be admitted to the hospital. Why stop there? Why not admit everyone who walks through the door for observation? My statement is absurd but where do you reasonably draw the line? In an era of cost cutting, government attempts at reducing hospital admissions and ER visits, it is just not feasible to admit every chest pain patient. At some point, judgment must be used and that is what board-certified emergency physicians are trained to do. We are human and are not infallible however; there are ways to minimize judgment errors.
The study from Wayne State that was quoted would suggest we do MRI’s on every person who presents to the ER with nausea and dizziness. Again, this can be done but the cost would be enormous! If this were standard of care, hospitals would have to provide dedicated MRI units for every ER in the country and the staff to run those 24 hours a day.
I have to disagree with the “more testing for all” philosophy in reducing errors, but agree the key is process design to improve data delivery, teamwork, communication, and patient education. Critically looking at ones mistakes through a robust peer review process can also provide quality improvements to reduce future mistakes.