Healthcare is essentially beneficial for patients, but it may also expose patients to adverse events and medical errors, ultimately resulting in harm or even death. International studies have reported that adverse events during hospital admissions affect nearly one out of 10 patients, and about 50% of these adverse events are preventable 1. Similar figures have been reported in Sweden. More precisely, of 1.2 million hospital admissions in somatic care during one year, about 105 000 preventable adverse events occur 2. Emergency departments (EDs) have a primary position in healthcare in that a high percentage of patients have their first contact with hospital care in EDs 3. The ED environment has been described as complex, dynamic, and vulnerable to medical errors 4,54,5, and being at high risk for medical errors with serious consequences for patients 6. Risk areas in the ED are, among others, related to communication, competence, triage, accessibility, and medication management 3,7,83,7,83,7,8, and up to 3% of all medical errors in hospitals take place in the EDs 9.
Research is growing internationally regarding patient safety in the EDs, with findings indicating that overcrowding, multitasking (managing multiple tasks simultaneously), and frequent interruptions contribute to medical errors 5,105,10. In general, the assumption is that many similar medical errors occur, but, for several reasons, they are not always reported and thus the number of unknown errors is assumed to be large 6,11,126,11,126,11,12. In Sweden, there is a lack of national overview of occurrence, causes, and types of medical errors and complaints pertaining to ED care.
Currently, many terms are used in the Swedish and international literature on patient safety. Terms and definitions used in this article are mentioned below:
Adverse event: an injury or a complication that is caused by medical management or interventions, rather than the underlying disease 13,1413,14.
Medical error: an error made in the process of care that results in or has the potential to result in harm to patients 6,146,14.
Complaint: perceived medical error made by patients or their proxies.
Research on ED care in Sweden is in an initial phase, and there is a lack of knowledge on patient safety in ED care. No comprehensive national or regional reports are available that describe the presence and types of reported complaints and medical errors in ED care. Therefore, the aim of this study was to describe the incidence and types of reported complaints and medical errors occurring in Swedish EDs during a 1-year period on the basis of available local, regional, and national registries.
This study used a descriptive design based on data from all regional and national registries managing complaints and medical errors.
The sample comprised all reported complaints and medical errors from Swedish EDs in 2009 to three national authorities. The National Board of Health and Welfare manages actual adverse events and medical errors reported by care providers and complaints filed by patients or their proxies. Until 2011, patients or their proxies could also file a complaint to the Medical Responsibility Board. There are compulsory regional Patients Advisory Committees (n=21) to which patients or their proxies can turn to if they have complaints regarding the care or treatment they have received. Further, reports regarding medical errors from local incident-reporting systems from all hospital-based EDs for somatically ill and injured adults in Sweden (n=72) were assessed.
Because no pre-existing questionnaire addressing the aim was available, the present research team developed a questionnaire directed to EDs. The questionnaire comprised 16 questions pertaining to the number, types, and the classification of medical errors reported by staff. Further questions covered the number of ED patient visits per year, the catchment area, the type of hospital, the type and name of local incident-reporting systems, and finally, questions about if and how the follow-up of medical errors was performed. Nurses responsible for the incident-reporting system tested the questionnaire at the EDs of one county and one local hospital. The results of this pilot test were discussed within the research team and subsequent minor revisions were implemented.
The National Board of Health and Welfare
During 2009, there were 1346 cases of medical errors reported from care providers to the authority; 524 of these cases were sorted under somatic specialized care, where cases from EDs were assumed to be found. As depicted in Fig. 1, the screening process was performed in two stages. In the first stage, the first author, an experienced ED nurse, screened all 524 case files to identify medical errors that had occurred at the EDs. However, several cases were duplicates, resulting in 428 unique cases.
The inclusion criteria for the first screening included the following: the department was a hospital-based ED for somatically ill and injured adults, the heading of the case contained the word ED or the description of the medical error indicated the possibility that it was related to ED care. The exclusion criteria were that the medical error had occurred in a nonhospital ED or at a specialized ED for children or if the heading and its description indicated that the medical error was not related to the ED. To reach consensus, the research group then reviewed this first screening process. In the second stage, these cases were ordered in full text from the authority and read through by the first author. The exclusion criterion was that the medical errors from the cases did not involve EDs, resulting in a final sample of 64 cases (Fig. 1).
The Medical Responsibility Board
In all, 4629 complaints about perceived medical errors were reported from patients or their proxies to the Medical Responsibility Board in 2009. One complaint was a duplicate, resulting in 4628 unique complaints. The decisions from the board were screened in two stages to capture complaints that had involved ED care (Fig. 2). The inclusion and exclusion criteria for the initial screening were the same as for the National Board of Health and Welfare. In the second stage, the first author read through the remaining decisions. All complaints that involved ED care were included, resulting in a final sample of 306 cases. Exclusion criteria were complaints not involving ED care, incomplete complaints, statute-barred (more than 2 years old), withdrawn complaints, or complaints directed to the regional Patients Advisory Committees that had not been handled by the board.
The Patients Advisory Committees
All 21 regional Patients Advisory Committees were contacted by e-mail and asked for statistics regarding the number and types of complaints in ED care during 2009. Reminders were sent three times to the nonresponding committees in intervals of 3 weeks, eventually resulting in responses from all 21 committees.
The local incident-reporting systems
The questionnaire for the national survey of local incident-reporting systems was sent to the head of the department of all 72 EDs in Swedish hospitals. Reminders were sent to the nonresponding EDs after 2 weeks and again after 4 weeks. Further reminders were made by telephone calls and e-mail during the following 2 months, resulting in a final sample of 47 EDs (65%). The respondents represented EDs from 19 local, 19 county, and nine university hospitals. The nonresponding EDs constituted 20 local, four county, and one university hospital.
A qualitative content analysis approach was used 15. The cases from the National Board of Health and Welfare and from the Medical Responsibility Board were read in their entirety to get a general sense of the case. The next step of analysis contained the identification of meaning units, that is, the constellation of words or statements that relate to the same central meaning 15. The meaning units were then condensed into codes (e.g. ‘insufficient examination’). In the final step of the analysis, categories emerged based on the codes. A sample of 5% of the cases was analyzed independently by four of the present researchers for the purpose of establishing consensus on the coding and categorization. Revisions were made until consensus was achieved.
Although the committees already categorized the complaints from the Patients Advisory Committees, the level of detail of this categorization varied. Eight (38%) committees reported the type of complaint in main categories, whereas 12 committees (57%) reported both main and subcategories based on common predefined categories established by the Patients Advisory Committees. One committee reported only the number of complaints. No analysis was carried out in that we did not have access to the original complaints and therefore the predefined categories by the Committees were used.
Medical errors reported from the local incident-reporting systems were presented in varying levels of detail (e.g. only the number of medical errors, numbers and types of medical errors, or in predefined categories). In the analysis, types of medical errors and the predefined categories of medical errors were coded, with the coded medical errors with similar characteristics being categorized together. The research group discussed and revised the categorizations until consensus was reached.
The study was approved by the Regional Ethical Review Board in Stockholm (Dnr: 2009/1413-31/4). The filed reports of the medical errors and complaints to all the above-mentioned authorities are publicly accessible documents, and no personal identifiable data were used.
Medical errors reported to the National Board of Health and Welfare
Out of 428 cases in somatic specialized care, 64 (15%) involved ED care. Because several cases contained more than one medical error, 92 medical errors were identified and subsequently classified into eight categories. Forty-two percent of the reported medical errors from healthcare providers concerned diagnostic procedures, followed by errors related to information/communication (19.6%) (Table 1).
Complaints of perceived medical errors reported to the Medical Responsibility Board
From 4628 cases, 306 (6.6%) were found to involve ED care. Because several cases contained more than one complaint, 437 complaints involving perceived medical errors were identified and subsequently classified into 11 categories (Table 1). Medical errors of diagnostic procedures (43.2%) were the most commonly reported complaints from patients, followed by complaints related to care and treatment (33.4%).
Complaints of perceived medical errors reported to the Patients Advisory Committees
During 2009, the regional Patients Advisory Committees (n=21) reported 1341 patient complaints in ED care (Table 2). Nearly half (48.8%) of the complaints were related to care and treatment. From the 12 (57%) committees that also reported data on the subcategory level, the main category care and treatment comprised the following subcategories: diagnosis/treatment (65.8%), nursing care (10.2%), blood specimen collection/examination (2.6%), medication (2.3%), technical equipment (0.1%), assistive device (0%), and unspecified (19.0%).
Medical errors reported to the local incident-reporting systems
Of the 47 responding EDs, 45 reported 1 666 506 ED visits per year in a catchment area of 6 612 600 inhabitants (or about 73% of the Swedish population). Of these EDs, 43 reported the use of eight incident-reporting systems, and healthcare staff reported 7434 medical errors in ED care during 2009. Of these medical errors, 1450 (19.5%) were related to care and treatment, closely followed by 1405 (18.9%) related to organization, routines, and resources (Table 3). Of the reported 7434 medical errors, 1302 (17.5%) were unspecified.
Reported medical errors and complaints in emergency department care during 2009 from national, regional, and local registries
Medical errors and complaints related to diagnostic procedures were reported most frequently to the National Board of Health and Welfare and to the Medical Responsibility Board (Table 4). Medical errors and complaints related to care and treatment were reported most often to the local incident-reporting systems and to the Patients Advisory Committees.
In all registries combined, the most common category of medical errors and complaints was related to care and treatment (24.3%), followed by organization, routines and resources (19.0%), and unspecified medical errors (14.5%) (Table 4).
This study provides a unique presentation of all reported medical errors and complaints originating from Swedish EDs in 2009. However, not all of the reported complaints were actual medical errors. The complaints sometimes related to situations, such as waiting times, as illustrated in Table 1, that did not necessarily result in a medical error. It should be noted that the result represents only the reported medical errors and complaints of perceived medical errors. Therefore, the results can be used only as an indication of the types and the extent of medical errors, and not as an accurate representation of the full extent of actual medical errors in ED care. The main finding is that medical errors and complaints reported by healthcare providers and patients to the National Board of Health and Welfare and the Medical Responsibility Board were mainly related to diagnostic procedures. Further, according to the reports from the local incident-reporting systems at the EDs and the complaints to the regional Patient Advisory Committees, the most common medical errors and complaints were those concerning care and treatment. However, in the main category care and treatment, as reported from the Patient Advisory Committees, a large part of the complaints was subcategorized as diagnosis/treatment (431/655). When the data sources were combined, the most common category of medical errors and complaints was care and treatment (24.3%), followed by organization, routines and resources (19.0%), and unspecified (14.5%).
The finding that the most commonly reported medical errors and complaints were related to diagnostic procedures confirms previous findings 10,16,1710,16,1710,16,17. Diagnostic and treatment phases in the ED are when medical errors are most likely to occur 17. Medical errors in the diagnostic process are more likely to occur and result in severe harm to patients than other medical errors in the ED 18–2018–2018–20. On the basis of the four data sources used in this study, there were 9304 medical errors and complaints reported in ED care in 2009, which constitute approximately 0.5% of the ED visits. On the basis of the calculations reported by the National Board of Health and Welfare (2004), approximately 1 000 000 medical errors per year are reported to local incident-reporting systems, representing all Swedish healthcare areas (hospital, primary care, dental care, nursing homes, psychiatry). Thus, the medical errors taking place at the EDs represented less than 1% of all reported medical errors to local incident-reporting systems. Previous research based on reviews of patient records has estimated that 3% of all hospital errors occur at EDs 9. The finding that approximately 1% of hospital errors took place at Swedish EDs is not reliable because of the assumed underreporting in incident-reporting systems, and the fact that many errors go unnoticed by healthcare staff 6,11–136,11–136,11–136,11–13.
Limitations and strengths
Problems exist when comparing data from different information sources because of potential differences in the use of terminology and the precision and presentation of data. In this study, the varying degrees of severity of the reported medical errors and complaints are a limitation. Further, the level of detail of information and terms used in the different data sources varied considerably, which is largely due to the lack of standardization in terminology and categories. The level of information detail varied between the Patient Advisory Committees. Of the 47 participating EDs, 43 reported eight local incident-reporting systems in use. The categorizations of medical errors were similar, but there was a lack of standardization. Too many, complex, and different incident-reporting systems in use both nationally and internationally complicate making comparisons 12 and probably contribute to underreporting.
Although they are national agencies, neither the National Board of Health and Welfare nor the Medical Responsibility Board used a standardized system for classification or categorization of medical errors and complaints.
Credibility is strengthened by the independent analysis of four of the researchers on a sample of the cases from the National Board of Health and Welfare and the Medical Responsibility Board. The inclusion criteria in the first screening stage were deliberately wide in an attempt to reduce the risk of missing relevant cases. Although the four data sources differed in the level of detail and who had reported the medical errors and complaints (i.e. patients, care providers, and healthcare staff), the results indicate that the types of reported medical error and complaint from the different data sources were similar. The sample consists of all reported medical errors and complaints during 1 year from EDs on a national level, which makes transferability to Swedish EDs possible, although it should be acknowledged that there probably is a considerable underreporting of cases.
The present results underscore the need for the development and implementation of national and international standards for terminology in the patient safety area and a standard for classification of medical errors in local incident-reporting systems. One possible way to develop such terminology is to implement the definitions proposed by the WHO 21 on a national level, which could be used by national authorities and local incident-reporting systems and the Patient Advisory Committees. It may be useful in future research to clarify and subdivide categories, such as care and treatment and diagnostic procedures. Despite the lack of standardization and the substantial proportion of unspecified medical errors and complaints, this paper provides the first presentation of a national overview of reported medical errors and complaints in Swedish EDs on the basis of available registries.
The results indicate that reported medical errors and complaints from care providers, healthcare staff, and patients mainly concerned diagnostic procedures and treatment and organizational matters. Further research is needed on the causes and outcomes of actual medical errors in order to provide a basis for actions to be taken to increase patient safety in ED care.
The authors would like to thank the Centre for Clinical Research (CKF), Dalarna, and Agneta Göransson, the head of the Department of Emergency Medicine, Falun Hospital, for providing financial support.
Conflicts of interest
There are no conflicts of interest.
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