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In this article, Sheila King, Clinical Risk Advisor, outlines learning from incidents occurring in emergency departments and presents advice to assist staff working in emergency medicine services to mitigate the risk of patient safety incidents.

Emergency medicine provides an essential service for service users and communities and fulfils a unique and crucial remit within the national healthcare system.1

The State Claims Agency completed a review of incidents on the National Incident Management System (NIMS), relating to the service of emergency medicine in the second quarter of 2022. These incidents were reported by emergency departments, clinical decision units, local injury units, urgent care centres, acute medical short stay units, and medical and surgical assessment units. A total of 1,465 service user incidents were reported on NIMS during this timeframe.

This article presents the learnings from those incidents as well as risk management advice to assist those working in emergency medicine services to mitigate the risk of patient safety incidents.

Incident analysis

Most incidents (88%) were reported as negligible or minor in severity, with less than 1% of incidents resulting in significant injury. The majority of incidents (59%) related to clinical care.

Clinical care incidents included those related to emergency department capacity, such as overcrowding (for example, demand exceeding bed/trolley numbers available, accommodation of patients in corridors), and emergency department staffing, resulting in prolonged waiting times and deficits in the monitoring of patients. Prolonged waiting time for clinician assessment following triage was reported to have resulted in service user deterioration. Other reported emergency department capacity incidents resulted in delayed, incomplete, or omitted care.

Clinical care incidents also arose where there was a lack of clear referral pathways and processes between teams/services and ineffective inter-team communication. These often resulted in delays in service users’ assessment and/or care.

Slips, trips and falls incidents were also reported. A significant number of these were unwitnessed, and inadequate staffing levels to provide sufficient observation/assistance to service users may have contributed to these incidents.

Other reported incidents included those relating to service users taking their own discharge and incidents of patients harming themselves in the emergency department.

Issues related to staffing levels and the physical capacity of the emergency department featured in many of the incidents reported.

Risk Advice

Based on our analysis of these incidents, we provide the following key advice for frontline and healthcare management staff:

Advice for frontline staff:

  • The care of service users with complex profiles and/or identified as being high risk at triage should be prioritised and escalated where appropriate.
  • Service users who experience prolonged waiting times for clinician assessment should be observed and monitored in order to identify those at risk of clinical deterioration and ensure appropriate care is provided. In particular, the Emergency Medicine Early Warning Score (EM EWS) should be used from triage to discharge, to support the recognition of and response to deteriorating patients. Clinical pathways, referral and escalation protocols should be clearly communicated to all staff to ensure timely assessment and care.
  • Attention should be paid to effective communication between health and social care personnel, particularly in relation to clinical information and handover of care.
  • Collaborative cooperation between teams should be promoted and encouraged.
  • Falls risk assessments should be undertaken as part of the nursing assessment, to identify service users who are at increased risk of falls and to implement preventative measures. Consideration should be given to the use of available emergency department-specific fall risk assessment tools.

Advice for healthcare management:

  • System processes and work practices should be in place to deal with overcrowding.
  • Risk assessments of overcrowding and patient flow should be undertaken and, where possible, mitigating actions implemented to reduce the risk of patient safety incidents.
  • Action plans should be developed and implemented to reduce the risk of harm to service users while awaiting assessment/care.
  • Staff levels and skill mix should be monitored and managed to ensure appropriate cover and expertise in dealing with service demands at times of high activity.
  • Emergency department waiting times should be audited and measured against national targets.

References available upon request.

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