By Jennifer Larson,
NurseZone feature writer
Commission on the Accreditation of Healthcare Organizations released a sentinel
event alert June 17 showing that these events can and do occur in many hospital
departments, not just in the emergency department.
to the alert, emergency departments are the source for about half of the
reported event cases of patient death or permanent injury due to delays in
treatment. However, serious events also occur in intensive care units,
medical-surgical units and other hospital departments.
looked at 55 reported cases of delays in treatment and found that 29 cases
originated from emergency departments, while 26 cases originated in hospital
intensive care units, medical-surgical units, inpatient psychiatric hospitals,
the operating room, freestanding and hospital-based ambulatory care services,
and in the home care setting. Patient death resulted in 52 of the 55 cases of
delays in treatment.
accounted for 42 percent of the delays in treatment. Delayed test results,
physician unavailability, incomplete treatment, delayed administration of
ordered care, a patient left unattended, paging system malfunction, delayed
initial assessment and a patient’s inability to find the emergency room
entrance were cited as other reported factors contributing to delay in
reported 23 cases of misdiagnosis, with meningitis cited as the most frequently
also reported that there are multiple root causes for such occurrences. Most
organizations cited a breakdown in communication, most often with or
between physicians, according to JCAHO. Other factors included patient
assessment process, continuum of care issues which most often related to
discontinuity of care across settings or shifts, orientation and training of
staff, availability of critical patient information, staffing levels and
availability of physician specialists.
was the most commonly cited root cause in emergency departments, accounting for
34 percent. Overcrowding was cited as a contributing factor in 31 percent of the
emergency department cases.
issued recommendations that hospitals implement processes and procedures to
improve staff-to-staff communication, including communication between resident
and attending physicians. It also recommended that hospitals implement
face-to-face interdisciplinary change-of-shift debriefings and find ways to
reduce staff reliance on verbal orders or institute a verification process for
the use of verbal orders.
the commission suggested that hospital emergency departments institute
strategies to “maintain a high index of suspicion for meningitis.”
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