1. EMER Emergency Medicine Events Register @EmergMedER Clinical Analysis First 154 Incidents DR KIM HANSEN EMERGENCY PHYSICIAN THE PRINCE CHARLES HOSPITAL DEPUTY CHAIR, ACEM QUALITY SUBCOMMITTEE ACEM PATIENT SAFETY WORKING GROUP @DOCTOR__DORA EMER@ACEM.ORG.AU

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6. EMER Emergency Medicine Events Register @EmergMedER Results First 154 Incidents NOVEMBER 2012 – MARCH 2015 EMER@ACEM.ORG.AU

9. Entering the ED Total = 26 Patient identification error Triage ◦Incorrect score ◦Incorrect bed allocation Overcrowding EMER@ACEM.ORG.AU

10. Initial Ax / Treatment Total = 97 Diagnostic error Treatment issue / delay Medication error Failure to recognise severity Fall / Injury Documentation Handover EMER@ACEM.ORG.AU

12. Inpatient review Total = 27 Conflict between teams ◦majority inpatient refusal to accept patient at same or other hospital Prolonged ED LOS EMER@ACEM.ORG.AU

13. Post Discharge Total = 32 Unprofessional conduct ◦Use of social media ◦Uncontactable when on-call ◦Abusive language Self-discharge ◦Did Not Wait ◦Left After Treatment Commenced Unplanned Representation EMER@ACEM.ORG.AU

15. “A man should never be ashamed to own that he has been in the wrong, which is but saying in other words that he is wiser today than he was yesterday.” ― Alexander PopeAlexander Pope

16. Case Study Clinical Presentation – 5 year old female, fever, abdominal pain, diarrhoea, 3 days post return from Asia. Examination was benign, with soft abdomen and child appeared well. Represented 2 days later with worsening abdominal pain and fever. Assessed as tenderness in RIF with guarding and peritonism. WCC was 27.4, arranged for paediatric transfer and commenced IV ABs. Working diagnosis was Salmonella/Typhoid. Transfer was delayed by 28 hours due to delay in booking transport and capacity issues. Upon arrival at receiving hospital was taken to theatre with findings of perforated appendicitis with abscess formation. What happened? - Delays in care and transfer, incorrect initial diagnosis, with missed appendicitis and complications. EMER@ACEM.ORG.AU

17. Case Study Contributing factors: Delays related to inadequate attention given to a child who re-presented with worsening clinical condition and fever. How could the incident have been prevented? Attention to unwell febrile child who re-presents; earlier senior review. Factors that reduced the impact of the incident: Senior review in morning with clinical review and expedited transfer. Consequence or Outcome: Delayed referral to surgery, and prolonged hospital admission. EMER@ACEM.ORG.AU

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