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PUBLIC RELEASE DATE:
17-Sep-2009

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Contact: Charlotte Webber
charlotte.webber@biomedcentral.com
44-020-319-22129
BioMed Central
@biomedcentral

Majority of unintended incidents in the ER are caused by human error

Sixty percent of the causes of unintended incidents in the emergency department that could have compromised patient safety are related to human failures, according to a study published in the open access journal BMC Emergency Medicine.

Hospitals and emergency departments are challenging settings with regard to patient safety -- a considerable number of patients suffer from unintended harm caused by healthcare management. Little is known about the causes of unintended events and, thus, these results from Marleen Smits and colleagues from Netherlands Institute for Health Services Research and EMGO Institute for Health and Care Research, may help to target research and interventions to increase patient safety.

The Dutch team studied emergency departments at 10 hospitals in the Netherlands for 8-14 weeks, during which staff were asked to report unintended events, defined as all unintended incidents that could have harmed or did harm a patient.

A total of 522 unintended events were reported, of which more than half of the events had consequences for the patient. A quarter of the reported events related to cooperation between the emergency department and other hospital departments. The team found that most root causes were human (60%), followed by organizational (25%) and technical (11%). Nearly half of the causes were attributable to departments outside the emergency department, such as the laboratory.

Event reports are internationally relevant for healthcare providers and policy makers in the area of emergency medicine. Smits said, "Patient safety in the emergency setting should be improved, especially the collaboration with other hospital departments".

All general hospitals in the Netherlands participate in the safety program "Prevent harm, work safely". They are setting up safety management systems that include incident reporting systems. Moreover, hospitals follow action plans on 10 themes with a high potential for reduction of unintended harm, for example, early detection of a decline in a patient's vital signs, medication verification and prevention of substitutions of patients.

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Notes to Editors:

1. The nature and causes of unintended events reported at ten emergency departments
Marleen Smits, Peter P Groenewegen, Danielle RM Timmermans, Gerrit van der Wal and Cordula Wagner
BMC Emergency Medicine (in press)

During embargo, article available here: http://www.biomedcentral.com/imedia/5433663312442972_article.pdf?random=911016

After the embargo, article available at journal website: http://www.biomedcentral.com/bmcemergmed/

Please name the journal in any story you write. If you are writing for the web, please link to the article. All articles are available free of charge, according to BioMed Central's open access policy.

Article citation and URL available on request at press@biomedcentral.com on the day of publication

2. BMC Emergency Medicine (http://www.biomedcentral.com/bmcemergmed/) is an open access journal publishing original peer-reviewed research articles in all aspects of emergency medicine, trauma, and pre-hospital care. BMC Emergency Medicine (ISSN 1471-227X) is indexed/tracked/covered by PubMed, CAS, Scopus, EMBASE and Google Scholar.

3. BioMed Central (http://www.biomedcentral.com/) is an STM (Science, Technology and Medicine) publisher which has pioneered the open access publishing model. All peer-reviewed research articles published by BioMed Central are made immediately and freely accessible online, and are licensed to allow redistribution and reuse. BioMed Central is part of Springer Science+Business Media, a leading global publisher in the STM sector.



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