National Healthcare Quality and Disparities Report
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
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1 to 1 of 1 Research Studies DisplayedGriffey RT, Schneider RM, Todorov AA
Near-miss events detected using the emergency department trigger tool.
The purpose of this study was to explore near misses and their significance for quality and safety in the emergency department (ED). This study presents a secondary analysis of data from a retrospective investigation of the ED Trigger Tool (EDTT) at an urban, academic ED. The EDTT, a computerized query for triggers, was applied to 13 months of ED visit data, and 5582 selected records were reviewed using a two-tiered approach. Events were categorized by occurrence (ED vs. present on arrival [POA]), severity, omission/commission, and type, employing a taxonomy featuring categories, subcategories, and cross-cutting modifiers. The researchers identified 1458 ED near misses in 1269 of the 5582 records and 80 near misses that were POA. Patient care events constituted the majority of ED near misses, including diagnostic delays, treatment delays, and monitoring failures, primarily influenced by ED boarding and overcrowding. Medication events ranked second in frequency (17%), with 80 medication administration errors identified. Among the 80 POA events, 42% were linked to overanticoagulation. It was estimated that 19.3% of all ED visits involved a near miss.
AHRQ-funded; HS027811; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
Near-miss events detected using the emergency department trigger tool.
J Patient Saf 2023 Mar 1; 19(2):59-66. doi: 10.1097/pts.0000000000001092..
Keywords: Emergency Department, Patient Safety, Adverse Events, Medical Errors