Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety – an analysis in a Finnish teaching hospital
Dublin Core
Title
Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety – an analysis in a Finnish teaching hospital
Subject
Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports.
The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety.
The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety.
Description
Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%).
In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems.
Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted.
Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding.
In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems.
Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted.
Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding.
Creator
Minna Halinen, Hanna Tiirinki, Auvo Rauhala, Sanna Kiili & Tuija Ikonen
Source
https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-024-01120-9
Publisher
BMC Emergency Medicine
Date
07 november 2024
Contributor
Fajar bagus W
Format
PDF
Language
English
Type
Text
Files
Collection
Citation
Minna Halinen, Hanna Tiirinki, Auvo Rauhala, Sanna Kiili & Tuija Ikonen , “Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety – an analysis in a Finnish teaching hospital,” Repository Horizon University Indonesia, accessed July 29, 2025, https://repository.horizon.ac.id/items/show/9421.