Errors in the emergency department that lead to adverse events have many contributors. Health care professionals often refer to adverse events as “never events” because they are preventable and should never happen.
According to StatPearls, research has highlighted many common threads among never events in emergency departments.
One review of emergency medicine claims revealed that diagnostic errors are a major issue. Diagnosis errors include:
- Failure to distinguish the correct condition
- Failure to order the correct tests
- Failure to address any findings that are abnormal
- Failure to consider the clinical information available
- Failure to obtain a consult
- Premature discharge from the emergency department
Why did doctors make these sometimes fatal diagnostic mistakes? The study indicates that contributing factors include bias regarding patient characteristics such as obesity, poor hygiene and mental illness.
A break-down in communication between providers also caused issues. Doctors did not have strong professional rapport or simply failed to contact the patient’s regular provider or specialist. Doctors also failed to review medical records.
Death after discharge
Another study addressed unanticipated deaths after emergency department discharge that occurred within seven days. These happened at a rate of 30 deaths per 100,000 patient discharges. Half of that number was the result of unexpected deaths related to the visit, and 60% of them had a possible contributing error.
Nearly all the patients who died had abnormal vital signs at discharge. However, many also had chronic diseases or unusual problems that did not present some of the traditional features.
While doctors made many of these mistakes, the professional literature suggests that addressing issues at the system level rather than the individual level may prevent much of the miscommunication and bias that lead to fatal errors.