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Don't Wait

By Jock Hoffman, CRICO

Related to: Communication, Diagnosis, Emergency Medicine

Each year, approximately one-third of Americans visit a hospital Emergency Department (ED). Those who are suddenly sick, injured, or out of other health care options often encounter EDs that are crowded, chaotic, and increasingly risky. More and more, patients are being diverted to other facilities or—intolerant of extraordinary wait times—choosing to leave without being seen. Even patients who are admitted to the hospital may face the risk of extended ED boarding before they are physically transferred to the admitting service. If EDs have not already reached the tipping point in patient safety risk, they are close.


The ED utilization rate grew seven percent from 1995–2005 and is expected to continue upward. A concurrent national decline in ED facilities and reimbursement rates is further stressing capacity and efficiency. With higher ED volume, patients experience longer waits, longer stays, and lower satisfaction…a scenario with the potential for increased adverse events, dissatisfied patients, and more malpractice lawsuits. From 2002–2006, CRICO saw 12.6 ED-related malpractice cases per year, representing $33 million in incurred losses, with an upward trend especially for physicians who practice Emergency Medicine.

ED-related malpractice cases expose risks in every phase of care from triage to diagnosis to discharge to test results received after the patient has gone home. The largest percentage of cases allege diagnostic errors: in particular, diagnostic fixation, substandard communication among providers, and premature discharge. Inadequate test results management and poor decisions regarding specialty consults are also common factors in ED cases.

Our Recommendation

Even if you think that your ED has a low risk profile, don’t wait to begin your next improvement project. Work now to preemptively identify and remedy your most egregious risks before they are exposed by a plaintiff’s allegations. For example, in 2006, CRICO/RMF developed a consensus statement with its insured institutions to address the risks related to inpatient boarding. In 2007, Boston’s Beth Israel Deaconess Medical Center launched an ED dashboard to improve the tracking of patients, test results, and specialty consults. In 2008, seven Harvard-affiliated EDs will participate in a team training/communication initiative aimed at improving patient handoffs.

These three Harvard ED initiatives are a small sample of a national undertaking to get ahead of what appears to be a looming convergence of risk, patient injury, and increased allegations of malpractice. At this stage, it is too early to know which of these efforts will serve to reduce risks to patients and providers. But, as the successful programs gain exposure and adoption, perhaps a budding patient safety crisis can be averted.

December 1, 2007
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