1. Describe the characteristics that make the ED an error-prone environment.

2. Recognize some of the common heuristics that can lead to errors in diagnosis.

3. Apply methods that can create a culture based on teamwork and communication in the ED.

4. Utilize appropriate screening tests and algorithms to avoid missed injuries.

5. Avoid secondary injury when 2 competing injuries are present.

Approaches to Eliminating Common Mistakes
Paul A. Silka, MD, Associate Clinical Professor of Emergency Medicine, the Keck School of Medicine of the University of Southern California, and Vice Chair, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA

Medical errors: definition according to Institute of Medicine (IOM)—failure of planned action to be completed as intended or use of wrong plan to achieve aim; types of errors include diagnostic, treatment, preventive, and other; other errors include error in diagnosis or delay in diagnosis and failure to communicate (account for most errors in acute care setting); according to IOM—50,000 to 100,000 deaths annually due to medical errors; landmark analysis showed that, more commonly, medical errors caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them; costs of medical errors—loss of life; $17 to $29 billion annually in hospitals nationwide; loss of patient trust and satisfaction; frustration and loss of morale in health care providers; lower levels of population health and loss of productivity in workplace and school

Recommendations for improvement: establish national focus; identify and learn from errors; ensure safety of delivery of health care at bedside; raise performance standards and expectations for improvements in safety

Leapfrog Group: consortium of public and private sector group purchasers that created strategy to improve safety and quality; goals—reduce preventable medical mistakes; encourage health care providers to publicly report quality and outcomes; reward hospitals and physicians for improving quality, safety, and affordability; help consumers reap benefits by making smart health care decisions based on published data; early initiatives—use of computerized physician order entry; hospital referrals based on evidence of superior performance; intensive care units (ICUs) staffed by physicians trained in critical care on daily basis

Emergency department (ED): characteristics that predispose to error—high decision density; high cognitive load; background of chaos, with interruptions and distractions; Harvard Medical Practice study (Leape et al, 1991)—found that only 3% of errors occurred in ED setting, and high rate of adverse events associated with misdiagnosis; specific factors detailed included high presence of part-time physicians and physicians not trained in emergency medicine (EM); also, speed of work daunting and sickest patients came to ED; 3% of national expenditures in health care for EM

Case example: 56-yr-old otherwise healthy man presents with tachycardia

Errors in cognition: result in misdiagnosis; daily phenomenon in ED setting; heuristics—tools used to solve problems; help with functioning in high-acuity environments without having to think too deeply; availability—tendency to judge likelihood of event by ease with which relevant examples come to mind; anchoring—failure to consider multiple possibilities for given presentations or quickly latching on to single explanation or diagnosis; confirmation bias— tendency to search for or interpret new information in way that confirms one’s preconceptions; helps avoid information and interpretations that contradict previous beliefs; important to ask what else could be going on with patient

Reducing error in ED: Rosen hypothesized years ago that with addition of 24/7 attending coverage in EDs, possible to avert or minimize technical error; he quantified incidence of 17 life- or limb-threatening errors per 1000 patients; Leape conjectured that systems that rely on error-free human performance doomed to failure (caretakers imbued with belief that they must be infallible and also likely to associate errors with negligence); cornerstones in error reduction—understand causes of error and design systems to minimize these causes; make it difficult to do what cannot be undone (or make it possible to undo actions); make it easier to discover and correct errors; change attitude toward errors (admission and study of mistakes will permit improvement); forcing function—one of highest levels of patient safety interventions; behavior-shaping constraints that prevent people from making errors; also need to account for human factors; studies show 30% to 40% of ED errors due to team coordination problems; effective teamwork and communication key patient safety strategy

Creating culture based on teamwork and communication: cultures that embrace concepts of open communication thought to be highly reliable organizations; count on individuals not only having competency but also having core skill set, ie, situational awareness, appropriate assertion, ability to use structured conversations, and ability to use communication tools; situational awareness—ability to have overall perspective on ED at any given time; allows for shared understanding of situation at hand; allows for individuals to create common understanding of goals and discuss potential problems; allows individuals to monitor and report progress on ongoing basis and helps avoid tunnel vision; allows individuals to have and respect “red flags”; appropriate assertion—persistent effective polite disclosure of data or opinion that will improve safety (not license for hostile or aggressive communication); must be taught to physicians so they can imbue to care team; structured conversations—help to establish perspective, not about being right, but about being able to get things done; help avoid judgment and focus on common goal in depersonalized way; anchor conversation around common agreement; start with simple things (eye contact and first name); briefings—structured interaction used to attain clear and effective communication in timely manner; used routinely in high-reliability organizations (eg, aviation, nuclear power plants); enhance efficiency by allowing caregivers to have shared mental model; recognized as 2003 national patient safety goal; universal protocol or “time-out” (allows for briefing before procedure); should be concise and involve others (2-way); should seek suggestions and assess comfort level of team; first names preferable; should make eye contact with person; should be done before procedures or high-acuity cases; also when change of status occurs in patients and during hand-offs

Conclusions: literature confirms experience that ED high-risk setting (involves sick patients, dynamic, and has cognitive density) and generally weak in systems and processes that ensure patient safety; errors of cognition routine; focusing on systems important way to ensure patient safety, and team building least expensive way of accomplishing

Trauma: Missed Injuries
David B. Hoyt, MD, John E. Connolly Professor of Surgery, and Chair, Department of Surgery, University of California, Irvine, School of Medicine

Performance: gap theory—problems and adverse events occur when gaps present in care process; clinicians are gap closers who make processes safer; clinical performance—function of workload; increased by expertise; affected by fatigue; ultimately, ongoing responsibility of physicians as profession

Causes of errors: complex processes; incomplete information; haste; ineffective communication; inexperience; infrequent incidence; in trauma, tendency to underestimate injury when mechanism severe and patient presents with no obvious findings, and when mechanism of injury low-energy transfer yet patient presents with obvious findings

Head injury: minimal head injury—Glasgow Coma Scale (GCS) score of 14 to 15; often attributed to alcohol; serial examinations not precise; study concluded that safer to send patient home with responsible family member than to admit to hospital; normal neurologic examination and normal computed tomography (CT) 100% accurate; liberal routine use of CT justified; in tangential gunshot wound (GSW), failure to appreciate blast effect possible, and performing CT and observation necessary; potential for secondary injury—important to consider in head injury; cerebral blood flow creates ischemic threshold of ≈18 mL/100 g of tissue; at that point, metabolism uncoupled and glucose utilization decreased; in ≈40% of patients with traumatic brain injury, ischemic threshold achieved; as pressure increases, blood flow increases up to threshold, then reaches plateau, due to subsequent vasoconstriction; in traumatic brain injury, relationship broken (traumatic vasoparesis), resulting in increased intracranial pressure (ICP); intervention necessary with head positioning (neutral), avoiding BP extremes, early ICP monitoring, and avoiding hyperventilation; selective hypotensive resuscitation not for patients with head injuries; multiple-trauma work-up—typical work-up includes cervical spine x-rays, chest x-rays, and objective evaluation of abdomen (focused assessment with sonography for trauma [FAST] and CT), pelvis films, and extremity films; avoid secondary injury; competing priorities often present

Head injury and hemoperitoneum: University of California, San Diego, study found that 20% of patients who present with GCS score of 8 required craniotomy or significant manipulation of ICP pharmacologically (ICP monitoring necessary); University of California, Davis, study found that only lateralizing signs predicted need for operation (and need for CT); algorithm—screen with ultrasonography (US), and if small amount of blood present, perform head CT; if large amount of blood present and no time for CT, limited laparotomy with ICP monitoring and/or ventriculography to look for shift in ICP indicated

Head injury and aortic injury: potential for ICP increases during positioning, hypoventilation (particularly if using Carlen tube), aortic cross-clamping, and increased bleeding (heparin for bypass and cross-clamp hypertension); ≈40% of patients with aortic transection have head injury; if head injury and wide mediastinum present, obtain screening head CT; if patient at risk for increased ICP or bleeding, pursue nonoperative management; CT findings that predict increased ICP—compressed mesencephalic cisterns; midline shift; presence of subarachnoid blood

Head injury and orthopedic injury: during intraoperative intervention for orthopedic injury in first 24 hr, hypotension occurs at some point in ≈75% of cases; risk from operative delay includes poor functional outcome and pulmonary problems; speaker’s algorithm based on GCS score and CT results

Progression of injury: particularly true for frontal and temporal contusions (routinely repeat CT)

Facial injuries: underdiagnosed, particularly in intubated and unconscious patients; routine CT good practice

Neck injuries: blunt carotid injuries—diagnosis often delayed; no consistent algorithm used in trauma centers for screening; mechanism extension and external rotation; high-risk patient one with combined head and facial fracture or cervical spine fracture; consider duplex scanning (not reliable at base of skull; increasingly replaced by CT angiography); routine screening recommended

Esophageal injuries: plain film showing soft tissue gas clue; missed by endoscopy due to mucosal infolding, which occurs if esophagus not distended; with blunt mechanism, injury uncommon and potentially overlooked; if performing esophagography, necessary to place nasogastric tube proximally to instill contrast and distend esophagus, then obtain postevacuation film, looking for subtle areas of leakage; intraoperatively, necessary to expose esophagus and distend with methylene blue to rule out injury

Laryngeal injury: underdiagnosed if not considered; typically, clothesline-type of injury; patient may present with hoarseness and may have loss of lateralization of one of vocal cords; best work-up thin-slice CT

Tracheal transection: if necessary to provide emergency airway in tracheal transection, remembering that trachea retracts slightly enables endotracheal intubation

Chest injury: lung contusion may be mistaken for hemothorax; axial traverse GSW should be considered in missed contralateral injuries; chronic lung disease often mistaken for pneumothorax; right mainstem intubation possibly misinterpreted as tension pneumothorax (pulling tube back prevents misdiagnosis); aortic transection—study found that diagnostic failures due to initial interpretation of chest x-ray and inadequate response to wide mediastinum; avoided with liberal use of CT; transesophageal echocardiography (TEE) for screening acceptable but has false-negative results and dependent on ability of ultrasonographer; 2% to 5% of patients with aortic transaction have another vascular injury; in high-impact side crash with intrusion or frontal crash with narrow crash pattern, jerk of deceleration typical mechanism associated with aortic transection; missed cardiac injuries—≈25% of patients stable; vital signs and central venous pressure as screening tool not predictive; echocardiography best test (occasionally subxiphoid window and irrigation of pericardium more appropriate); blunt cardiac injuries increasingly seen; consider mechanism of injury in making diagnosis

Diaphragmatic injury: lavage criteria had false-negative rate; finger palpation of diaphragm through chest tube hole not accurate; serial outpatient chest x-rays unreliable; laparoscopy can be complicated by tension pneumothorax; CT has false-negative rate of 30%; no ideal test

Abdominal injury: liver and spleen injuries source of problems in “low-risk” patients deemed to not require objective evaluation of abdomen (less of problem, due to regular use of US); patients with pain, base deficit, or drop in hematocrit must have objective evaluation of abdomen; BP not reliable indicator of class 1 and class 2 hemorrhage; use of base deficit or lactate better method of screening for class 1 and 2 hemorrhagic shock; diagnostic peritoneal lavage (DPL) not ideal for pancreas, diaphragm, and bowel; CT not ideal for bowel and diaphragm; US not ideal for bowel; missing abdominal injuries intraoperatively often due to failure to adequately explore lesser sac and retroperitoneum in patient with multiple injuries; screen for injury to pancreas, using finer cuts (<5 mm) on CT (observe patient and repeat CT or explore if no improvement); nonoperative management for spleen and liver; major contrast extravasation from spleen or liver indication for angiography or laparotomy; if unable to find problem intraoperatively and patient continues to be hypotensive, consider retroperitoneal bleeding from kidney or gluteal artery

Pelvic injury: requires work-up of urologic system with cystography and urethrography; in straddle-type injury with large perineal laceration, consider possibility of rectal injury

Avoiding death spiral: hypothermia, coagulopathy, and acidosis; damage control important concept of “abbreviated surgery”; abdominal compartment syndrome—consider in context of decreased cardiac output, decreased urine output, and increased peak inspiratory pressures; screen with bladder pressure monitoring

Vascular injury: ankle-brachial index has false-negative rate of ≈15%; most injuries not significant and rarely limb- threatening; missed compartment syndrome bigger problem (screen aggressively by measuring compartment pressures; early fasciotomy required)

Orthopedic injury: most common missed injury; most misses in context of sick patient and often masked by more significant injury; if no algorithm, 5% of cervical spine injuries missed; rigid protocol for clearance best way to avoid missing; absence of back pain does not exclude injury; best way to avoid missing orthopedic injuries is to use tertiary survey (head-to-toe physical examination)

Conclusions: know injury pitfalls and focus work-up and diagnostic tests accordingly; aggressive follow-up and tertiary examinations recommended; use of algorithms best approach