What causes adverse events in prehospital care? A human-factors approach

Emergency Medicine Journal

Volumn 30, Issue 7, 2013, Pages 583-588

  Price, Roger ^a   Bendall, Jason C ^a   Patterson, Jillian A ^a   Middleton, Paul M ^a  

^a Greater Sydney Area Helicopter Emergency Medical Service Ambulance Service New South Wales Rescue Helicopter Base Bankstown Airport   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

ADVERSE OUTCOME; ARTICLE; CONTROLLED STUDY; EMERGENCY CARE; HEALTH CARE SURVEY; HUMAN; HUMAN FACTORS RESEARCH; MAJOR CLINICAL STUDY; MORTALITY; PRIORITY JOURNAL; RISK FACTOR;

CLINICAL MANAGEMENT; EMERGENCY AMBULANCE SYSTEMS; HUMAN FACTORS; MEDICAL ERROR; PARAMEDICS; PATIENT HARM EVENTS; PREHOSPITAL; PREHOSPITAL CARE;

ALLIED HEALTH PERSONNEL; AMBULANCES; ATTITUDE OF HEALTH PERSONNEL; AUSTRALIA; CAUSALITY; EMERGENCY MEDICAL SERVICES; HUMANS; MEDICAL ERRORS; NEW SOUTH WALES; PRINCIPAL COMPONENT ANALYSIS; PROCESS ASSESSMENT (HEALTH CARE); QUESTIONNAIRES; SAFETY MANAGEMENT;

EID: 84879411102     PISSN: 14720205     EISSN: 14720213     Source Type: Journal    
DOI: 10.1136/emermed-2011-200971     Document Type: Article

References (28)

1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safety Health System. Institute of Medicine. Washington, DC: National Academy Press, 1999.
2. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust 1995;163:458-71.
3. Meisel ZF, Hargarten S, Vernick J. Addressing prehospital patient safety using the science of injury prevention and control. Prehosp Emerg Care 2008;12:411-16.
4. Bigham B, Morrison L, Pitts R, et al. Patient Safety in Emergency Medical Services. Edmonton, Canadian Patient Safety Institute, 2010.
5. Bernius M, Thibodeau B, Jones A, et al. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care 2008;12:486-94.
6. Henriksen K, Dayton E, Keyes M, et al. Understanding adverse events: A human factors framework. 2008. Chapter 5. p7. www.ahrq.gov/qual/nurseshdbk/docs/ HenriksenK-UAE.pdf (accessed 5 Mar 2012).
7. Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196-205. (Pubitemid 46108135)
8. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493-9. (Pubitemid 41058029)
9. Campbell SG, Croskerry P, Bond WF. Profiles in patient safety: A "perfect storm" in the emergency department. Acad Emerg Med 2007;14:743-9. (Pubitemid 47064423)
10. Cretikos MA, Bellomo R, Hillman K, et al. Respiratory rate: The neglected vital sign. Med J Aust 2008;188:657-9.
11. Kause J, Smith G, Prytherch D, et al Intensive Care Society (UK); Australian and New Zealand Intensive Care Society Clinical Trials Group. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdomdthe ACADEMIA study. Resuscitation 2004;62:275-82. (Pubitemid 39119586)
12. McGaughey J, Alderdice F, Fowler R, et al. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007;(3): CD005529.
13. Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet 2005; 365:2091-7. (Pubitemid 40826966)
14. Atack L, Maher J. Emergency medical and health providers' perceptions of key issues in prehospital patient safety. Prehosp Emerg Care 2009;14:95-102.
15. Klein G. Sources of Power: How People Make Decisions. Cambridge, MA: Massachusetts Institute of Technology, 1998.
16. Farnan JM, Johnson JK, Meltzer DO, et al. Resident uncertainty in clinical decision making and impact on patient care: A qualitative study. Qual Saf Health Care 2008;17:122-6.
17. Hayward RA, Asch SM, Hogan MM, et al. Sins of omission: Getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med 2005;20:686-91. (Pubitemid 41140998)
18. Wears RL, Croskerry PG. Safety in Emergency Medicine. In: Markovchick VJ, Pons PT, eds. Emergency Medicine Secrets. 4th ed. Mosby Elsevier, Philadelphia, 2006.
19. Joint Commission on Accreditation of Healthcare Organizations. Root Causes and Percentages for Sentinel Events (All Categories) January 1995-December 2004.
20. http://www.jointcommission.org/assets/1/18/SE-RootCausesEventType2004- 4Q2010.pdf (accessed 10 Jun 2011).
21. St.Pierre M, Hofinger G, Buerschaper C, et al. Crisis Management in Acute Care Settings. Heidelberg: Springer, 2008.
22. Clinical Excellence Commission. Between the Flags Project: The Way Forward. Sydney, CEC, 2008.
23. Clancy CM, Tornberg DN. TeamSTEPPS: Assuring optimal teamwork in clinical settings. Am J Med Qual 2007;22:214-17.
24. Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from nonmedical near miss reporting systems. BMJ 2000;320:759-63. (Pubitemid 30179427)
25. Australian Commission on Safety and Quality in Healthcare. Recognising and Responding to Clinical Deterioration: Background Paper. Sydney, ACSQHC, 2008.
26. Hauswald M. Can paramedics safely decide which patients do not need ambulance transport or emergency department care? Prehosp Emerg Care 2002;6:383-6.
27. Cone DC, Wydro GC. Can basic life support personnel safely determine that advance life support is not needed? Prehosp Emerg Care 2001;5:360-5. (Pubitemid 32964224)
28. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154-7. (Pubitemid 28156466)