1. 1 EMER Emergency Medicine Events Register “Learning from our errors” Dr Carmel Crock and Ms Anita Deakin “Patient Experience Week” 28-29 th April, 2016 Perth, Australia

2. Emergency Medicine Events Register - 2015 London film presentation - Learning from our errors

3. High Risk/Reliability Organizations and Industries

4. Human Error: Models and Management “Perhaps the most important distinguishing feature of high reliability organisations is their collective preoccupation with the possibility of failure. They expect errors and train their workforce to recognise and recover from them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel ones…Instead of making local repairs, they look for system reforms.” Reason BMJ March 2000

5. What is EMER? Specialty-specific incident monitoring What happens in EDs? Why? What can we do to prevent these incidents? 5

6. Why do things go wrong in an ED? Is it our environment? Is it our training? Is it about how we communicate? 6

7. Benefits of EMER Raise awareness about error and safety Create a culture where it is safe to discuss error/near misses Honesty, openness Question how we do things How could I/we have done better? 7

8. EMER as a ‘debrief‘ tool Forgive ourselves after an error Pick ourselves up Error and shame –stress/depression Effect of an error on whole department 8

9. Rory Staunton

10. Quality =...... Learning from our error Communication – both between healthcare providers/ with patient Discharge instructions Results checking Partnering with patients for quality in EDs Healthy workplace/ Mentoring juniors

12. 12 Consumer Reporting “Complaints from patients and/or their carers are important indicators of problems in a healthcare system. The patient perspective is important because users of health services may have a different view of problems to those reported by health professionals in the adverse incident reporting systems that are now routine practice in many countries.” [1] “Integrating patients’ perspective broadens the existing understanding of adverse events…..” [1] “Of note, while concerns generated by patients and families most often did not lead to PSI (patient safety incident) identification, we feel strongly that their feedback is still highly valuable for understanding and improving the patient experience” [2] 1. Lang, S., Garrido, M.V., and Heintze, C. (2016) Patients’ views of adverse events in primary and ambulatory care: a systematic review to assess methods and the content of what patients consider to be adverse events. BMC Family Practice. 17:6 2. Reznek, M.A., Kotkowski, K.A., Arce, M.W., Jepson, Z.k., Bird, S.B., and Darling, C.E. (2015) Patient safety incident capture resulting from incident reports: a comparative observational analysis. BMC Emergency Medicine. 15:6

13. 13 EMER - Consumer Reporting Launched in 2016 Supported by ACEM and APSF First emergency medicine specific consumer reporting portal in Australasia Analysed by expert data analysts and reviewed by people directly involved in emergency medicine (ED directors and physicians, ACEM, consumer advocates) Enables problems to be reviewed across all hospitals and preventative strategies to be implemented accordingly

14. 14 Consumer Reporting – Why report? Anonymous, online, secure reporting system Easy to use Only takes 5-10 minutes to enter an incident Information fed back directly to the specialty Protected under Qualified Privilege Incidents are reviewed from the consumers perspective!

15. 15 What can I report? Care that didn’t go as expected or planned (e.g. Incorrect treatment/procedure performed etc) Care that went better than expected or planned (e.g. Staff member going above the “call of duty”) Anything that nearly went wrong – “near miss”. (e.g. nurse nearly administered the incorrect medication)

16. 16 Examples of reported incidents Patient bought a live snake in a plastic bag into ED Miscommunication between treating teams during patient inter-hospital transfer

17. 17 What happens with my report?

18. 18 Incident submitted Who did the experience happen to? Tell us what happenedWhat was the result of your experience? How could your experience have been prevented? What could the emergency department have done better? Age BandGenderCountryHow recently did your experience occur? time of the day Your childMy 5 year daughter was brought in to emergency with an elbow fracture requiring surgery. We had to be sent to a paediatric hospital and the doctors at the first ED spoke to a consultant orthopaedic surgeon, who was happy to take over her care/surgery at the paediatric hospital. We arrived at the paediatric ED and told the triage nurse, then the doctor and the nurse inside ED, that we were expected by the consultant orthopaedic surgeon. We waited and kept saying that the surgeon was expecting us (as she needed a pin in the elbow). She was in extreme pain. We did not seem to be able to 'get through' to any of the staff. After about 2 1/2 hours an orthopaedic registrar arrived and said "i don't know anything about you'. We said "no we were expected by the consultant orthopaedic surgeon about 3 hours ago. Registrar said "oh I'll go and let him know you've arrived'. We just couldn't get any of the staff in ED to listen to a very simple thing that we were saying. We could have saved them a lot if time and effort if they had listened to what we had to say. They all seemed so distracted. Just about a 3 hour delay, frustration for us as parents and pain for my child. Simple listening and when a parent or patient says something, assume it may be true. I work in healthcare and was amazed that I could not get my voice heard. When we arrived, I would have appreciated if the triage nurse could have just contacted the surgeon who had accepted us and let him know we had arrived. It seemed that everyone was afraid to just believe us and contact him. The communication practices in the ED seemed very chaotic. 5 to 9 yearsFemaleAustraliaMore than 12 months ago2:00 to 2:59 pm

19. 19 Incident de-identified and classified

20. 20 Data analysed Count of Burst reporting % Diagnostic Error (eg missed/delayed fracture diagnosis, dislocations, infections, myocardial infarcts, cancer, stroke, embolism, appendicitis) 1780.9 Airway Management (eg intubation, laryngoscopy, equipment failure, human error, system failure) 29.5 Medical Procedure (eg lumbar puncture, sedation, fracture reduction, advanced line insertion) 29.5 Grand Total21100

21. 21 Dissemination of learnings Schultz, T. J., Crock, C., Hansen, K., Deakin, A., & Gosbell, A. (2014). Piloting an online incident reporting system in Australasian emergency medicine. Emergency Medicine Australasia: EMA, 26(5), 461–7. Deakin, A., & Hansen, K. (2015). Why did you leave us when we wanted you to stay? Emergency Medicine Australasia. 27(5). 488–489 Thomas, M. J., Schultz, T. J., Hannaford, N., & Runciman, W. B. (2012). Failures in Transition: Learning from Incidents Relating to Clinical Handover in Acute Care. J Healthc Qual, Jan 23. Jones, D. N., & Crock, C. (2009). Parallel diagnostic universes: One patient. How radiologists and emergency physicians share diagnostic error. Journal of Medical Imaging and Radiation Oncology, 53, 143–151. Deakin, A., Schultz, TJ., Hansen, K., & Crock, C. (2014). Diagnostic error: Missed fractures in emergency medicine. Emergency Medicine Australasia: EMA.

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23. Where can I find “EMER”? http://www.emer.org.au/

24. 24 EMER Contacts Direct email emer@acem.org.au Anita.Deakin@unisa.edu.au Via the website

25. 25 “Please see me”