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Open Access Highly Accessed Research article

The nature and causes of unintended events reported at ten emergency departments

Marleen Smits1*, Peter P Groenewegen12, Danielle RM Timmermans3, Gerrit van der Wal3 and Cordula Wagner13

Author Affiliations

1 NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands

2 Department of Sociology and Department of Human Geography, Utrecht University, Utrecht, The Netherlands

3 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands

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BMC Emergency Medicine 2009, 9:16  doi:10.1186/1471-227X-9-16

Published: 18 September 2009

Abstract

Background

Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs) are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.

Methods

Study at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA) by an experienced researcher.

Results

522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%), followed by organisational (25%) and technical causes (11%). Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital.

Conclusion

Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.