EMERGENCY MEDICINE EVENTS REGISTER: A Clinical Analysis of Procedural Errors Follow us at @EmergMedER Visit us at emer.org.au Kim Hansen 1,2 Carmel Crock 3 Anita Deakin 4 Tim Schultz 4 William Runciman 4 Andrew Gosbell5 1. The Prince Charles Hospital, 2. The University of Queensland, 3. The Eye and Ear Hospital of Victoria, 4. Australian Patient Safety Foundation, 5. ACEM

Follow us at @EmergMedER Visit us at emer.org.au Introduction To capture and analyse adverse events, near misses and good saves that occur in Emergency Departments, we developed an online, anonymous incident reporting register called Emergency Medicine Events Register (EMER) at emer.org.au. Context: This Patient Safety project is a collaboration between the Australasian College for Emergency Medicine (ACEM) and the Australian Patient Safety Foundation (APSF). It is aimed specifically at doctors of all levels who work in Emergency Departments. Problem: Errors in medicine occur frequently and cause significant morbidity and mortality. Due to its chaotic nature, undifferentiated patients and variable levels of staff experience, the likelihood of patient harm in Emergency Departments is increased. Assessment of problem and analysis of its causes: Doctors rarely report using existing incident reporting systems. We encourage doctors to make relevant and informative entries that their colleagues could learn from.   Click HERE to go to emer.org.au Follow us at @EmergMedER Visit us at emer.org.au

Anonymous, Confidential and Protected Methods We created emer.org.au which allows reporting of adverse events where information is confidential, protected and anonymous. Intervention: At emer.org.au, the clinician remains anonymous and no patient or hospital details are recorded other than basic demographics. The website has a user-friendly design with only 4 pages of questions, most of which are drop-down boxes and non-compulsory. There is no registration, login or password required and the website is free to access. Study design: The EMER website, emer.org.au, was designed with expert input from Emergency Consultants on the ACEM Quality Sub-Committee and APSF staff.  EMER was launched in November 2012 and the website is open to for use by all Emergency Clinicians.  Analysis: We analysed the data for the demographics of patients involved in an event, triage score, the time taken to complete and entry and the delegation of the reporting clinician. Entries into EMER were analysed by a panel of expert clinicians to determine the clinical category of the incidents. Identify Report Improve Learn more about EMER Anonymous, Confidential and Protected

Follow us at @EmergMedER Visit us at emer.org.au Results The first 246 entries into EMER via emer.org.au from November 2012 to March 2016 were analysed. Analysis results: Each incident was categorised into up to 4 categories, creating 473 categories in total. The most common triage score was 3. It took under 5 minutes to enter an incident on average. Categories of EMER Incidents (Total=473) The most frequent incident categories are: Diagnostic (n = 95) Investigation (n = 62) Procedure (n = 53) There are multiple incidents of harm in the database, including eight deaths, and five incidents with irreversible harm to the patient. One staff member was electrocuted during a defibrillation. The most common procedural incident involved intubation. The other common procedural errors were intravenous access, ophthalmological procedures and procedural sedation. Follow us at @EmergMedER Visit us at emer.org.au

Procedural Errors Case Study There have been 53 reports in the EMER database involving procedures. Within the procedural incidents, other common categories of error include Failure to recognise deterioration, Equipment, Medication, Transport and Diagnostic errors. There were several reports of patient harm, including: 8 deaths 1 cardiac arrest and 1 respiratory arrest with successful resuscitation 2 oesophageal intubations 2 cricothyroidotomies and 1 needle cricothyroidotomy The most common role of the clinician involved in the incident was ED consultant, however over 95% of reporters were ED Consultants. What happened? Patient deteriorated in ED acute area, with increasing SOB. Moved to resus. ED Consultant attempted to intubate with RSI but unsuccessful. Anaesthetist called, requested glidescope, anti-fog and glycopyrollate, all of which were unavailable in ED. Video laryngoscope used but battery ran out prior to first attempt. Anaesthetist unable to intubate patient in ED despite multiple attempts. Patient able to be ventilated with BVM. How could the incident have been prevented? Additional preparation time for anaesthetist and surgeon with earlier warning. Standardisation of equipment and processes in hospital. Inter-departmental education sessions. Action Taken Patient was transported to OT while being ventilated with BVM (sats>90%). He was gassed down by anaesthetist with surgeons scrubbed and neck prepped. Epiglottitis seen on glidescope.

There are lessons to be learnt from medical errors. Conclusion The future for EMER: Further awareness of emer.org.au to increase the number and quality of entries into EMER is the key to its utility to the profession. The expansion of the database will allow patterns of harm to emerge and allow EMER to educate its fellows and members on changes necessary to enhance patient safety. There is regular reporting of the EMER results back to the critical care community via Twitter, Patient Safety Alerts and other mediums. From March 2016, patients are able to report into EMER as well. Click HERE to start video There are lessons to be learnt from medical errors. EMER provides the opportunity to collect incidents which can be used to improve patient safety. Follow us at @EmergMedER Visit us at emer.org.au