Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department.

BACKGROUND: Little is known about which methods are best for detecting adverse events in the emergency department (ED). OBJECTIVES: This study compared the ability of trigger tool and reporting methods to capture adverse events in the ED and investigated the characteristics of the adverse events identified by each. METHODS: This 1-year prospective observational cohort study evaluated a monitoring system that combined 2 reporting methods and 5 trigger tool methods to capture adverse events in the ED of an academic medical center. Measurement outcomes included the number, type, and physical impact of the captured adverse events. RESULTS: Among 69,327 adult nontrauma ED visits, 285 adverse events were identified. Of these adverse events, 77.2% were identified using reporting methods, 26% using trigger tool methods, and 3.2% using both methods. Most patients (81.7%) incurred temporary, minor physical impacts. Of the adverse events that occurred, 86.7% were related to clinical performance. Compared with reporting methods, trigger tool methods had a lower positive predictive rate to identify adverse events (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.09-0.16), a greater proportion of adverse events occurring during the preinterventation and postintervention phases (OR, 17.0; 95% CI, 8.48-34.16), and more cases of severe physical impact or death (OR, 5.4; 95% CI, 2.62-11.10). CONCLUSIONS: The reporting methods more effectively captured greater numbers of adverse events, whereas the adverse events captured by the trigger tool methods were more likely to be severe physical impacts. The combined use of the different methods had synergistic benefits for monitoring adverse events in the ED.

A 12-year analysis of closed medical malpractice claims of the Taiwan civil court: A retrospective study.

Malpractices lawsuits cause increased physician stress and decreased career satisfaction, which might result in defensive medicine for avoiding litigation. It is, consequently, important to learn experiences from previous malpractice claims. The aim of this study was to examine the epidemiologic factors related to medical malpractice claims, identify specialties at high risk of such claims, and determine clinical which errors tend to lead to medical malpractice lawsuits, by analyzing closed malpractice claims in the civil courts of Taiwan.The current analysis reviewed the verdicts of the Taiwan judicial system from a retrospective study using the population-based databank, focusing on 946 closed medical claims between 2002 and 2013.Among these medical malpractice claims, only 14.1% of the verdicts were against clinicians, with a mean indemnity payment of $83,350. The most common single specialty involved was obstetrics (10.7%), while the surgery group accounted for approximately 40% of the cases. In total, 46.3% of the patients named in the claims had either died or been gravely injured. Compared to the $75,632 indemnity for deceased patients, the mean indemnity payment for plaintiffs with grave outcomes was approximately 4.5 times higher. The diagnosis groups at high risk of malpractice litigation were infectious diseases (7.3%), malignancies (7.2%), and limb fractures (4.9%). A relatively low success rate was found in claims concerning undiagnosed congenital anomalies (4.5%) and infectious diseases (5.8%) group. A surgery dispute was the most frequent argument in civil malpractice claims (38.8%), followed by diagnosis error (19.3%).Clinicians represent 85.9% of the defendants who won their cases, but they spent an average of 4.7 years to reach final adjudication. Increased public education to prevent unrealistic expectations among patients is recommended to decrease frivolous lawsuits. Further investigation to improve the lengthy judicial process is also necessary to relieve the stress of medical malpractice claims on clinicians and practitioners, as well as on the judicial system and rightful claimants.

Learning from an analysis of closed malpractice litigation involving myocardial infarction.

OBJECTIVE: To examine the epidemiologic data, identify the pattern of dispute, and determine clinical litigious errors by analyzing closed malpractice claims involving myocardial infarction (MI) in Taiwanese courts. METHODS: A retrospective descriptive study was performed to analyze the verdicts pertaining to MI from the population-based database of the Taiwan judicial system between 2002 and 2013. The results of adjudication, involved specialists, primary dispute leading to lawsuits, and litigious errors were recorded. RESULTS: A total of 36 closed malpractice claims involving MI were included. The mean interval between the incident and litigation closure was 65.5 ± 28.3 months. Nearly 20% of the cases were judged against clinicians and the mean payment was $100639 ± 49617, while the mean imprisonment sentence was 4.3 ± 1.8 months. Cardiologists and emergency physicians were involved in 56.3% of cases, but won 92.6% of lawsuits, while other specialists lost nearly 25% of lawsuits. The most common dispute was misdiagnosis (38.9%), but this dispute had the lowest percentage of loss (7.1%). Disputes regarding delayed diagnosis were judged against the defendants in 50% of claims. Clinicians lost the lawsuit in the following conditions: 1) misdiagnosis of MI in patients with typical chest pain and known coronary artery risk factors; 2) failure to perform thoughtful evaluation and series investigations in patients suspicious of ischemic heart disease; 3) failure to perform indicated treatment to avoid disease progression. CONCLUSIONS: Medical practitioners should keep a high index of MI suspicion, especially if the diagnosis and treatment of MI are beyond their daily practice. Prudent patient reevaluation, serial ECG and cardiac enzyme testing, and early consultation are suggested to reduce malpractice liability.

An analysis of causative factors in closed criminal medical malpractice cases of the Taiwan Supreme Court: 2000-2014.

Most medical malpractice in Taiwan leads to criminal prosecution. This study examined the epidemiologic factors and clinical errors that led to medical malpractice convictions in Taiwanese criminal prosecutions. A retrospective, 15-year population-based review of criminal Supreme Court judgments pertaining to medical malpractice against physicians and nurses was conducted. Eighty-four cases were reviewed, yielding data that included the number and specialty involved, accused hospitals, the diagnosis, the time interval between incidents to closure, result of adjudication, the origin of cases (private vs. public prosecution), the result of medical appraisal, and the primary error. Overall, the cases averaged 7.6years to achieve final adjudication. Seventy-five percent were settled in favor of the clinician; twenty-three physicians and three nurses were found guilty, but all of these avoided imprisonment via probation or replacement with forfeit. The single most risky specialty was emergency medicine (22.6% of the cases), with 36.8% of those resulting in guilty verdicts. The most common diagnosis groups were infectious diseases (23.8%), intracranial hemorrhages (10.7%), and acute coronary syndrome (9.5%). Public prosecutions had a 41.2% conviction rate; no guilty verdicts resulted from private prosecution. Nineteen (22.6%) cases were commuted, and 73.7% of those had a controversial appraisal result. The characteristics of criminal malpractice prosecution in Taiwan that could be improved to relieve the stress of frivolous lawsuits on the judicial process include lengthy jurisdiction process; low public-prosecution conviction rate; frequent commuted jurisdiction related to a controversial appraisal; and zero imprisonment rate for clinicians.

The influence of emergency department crowding on the efficiency of care for acute stroke patients.

OBJECTIVE: To investigate the impact of emergency department (ED) crowding (number of ED patients) and number of ED staff on the efficiency of the ED care process for acute stroke patients. DESIGN: Retrospective cohort study conducted from 1 May 2008 to 31 December 2013. SETTING: Largest primary stroke center (3000-bed tertiary academic hospital) in southern Taiwan. PARTICIPANTS: Patients aged 18-80 years presenting to the ED with acute stroke symptoms ≤3 h from symptom onset (n = 1142). MAIN OUTCOME MEASURES: Door-to-assessment time (DTA), door-to-computed tomography completion time (DTCT) and door-to-needle time (DTN). RESULTS: Of the 785 patients with ischemic stroke, 90 (11.46%) received thrombolysis. In the multivariate regression analysis, the number of ED patients and the number of attending physicians were significantly associated with delayed DTA and DTCT but not DTN. Initial assessment by a resident was also associated with delayed DTA and DTCT. The number of nurses was associated with delayed DTCT and DTN. CONCLUSIONS: Although ED crowding was not associated with delayed DTN, it predicted delayed DTA and DTCT in thrombolysis-eligible stroke patients. The number of attending physicians affected initial assessment and DTCTs, whereas the number of nurses impacted thrombolytic administration times.

Physician Risk Tolerance and Head Computed Tomography Use for Patients with Isolated Headaches.

BACKGROUND: Headaches are one of the most common afflictions in adults and reasons for emergency department (ED) visits. OBJECTIVE: We sought to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with headaches in the ED. METHODS: We performed a retrospective study of patients with nontraumatic isolated headaches in the ED and then administered two instruments (Risk-Taking subscale [RTS] of the Jackson Personality Index and a Malpractice Fear Scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT scans. Outcomes were head CT use during ED evaluation and hospital admission. A hierarchical logistic regression was used to determine the effect of risk scales on head CT use. RESULTS: Of the 1328 patients with headaches, 521 (39.2%) received brain CTs and 83 (6.9%) were admitted; 33 (2.5%) patients received a final diagnosis that the central nervous system was the origin of the disease. Among the 17 emergency physicians (EPs), the median of the MFS and RTS was 23 (interquartile range [IQR] 19-25) and 21 (IQR 20-23), respectively. EPs who were relatively risk-averse and those who possessed a higher level of malpractice fear were not more likely to order brain CTs for patients with isolated headaches. CONCLUSIONS: Individual EP risk tolerance, as measured by RTS, and malpractice concerns, measured by MFS, were not predictive of CT use in patients with isolated headaches.

An analysis of closed medical litigations against the obstetrics departments in Taiwan from 2003 to 2012†.

OBJECTIVE: To examine the epidemiologic data of closed medical claims from Taiwanese civil courts against obstetric departments and identify high-risk diseases. DESIGN: A retrospective descriptive study. SETTING/STUDY PARTICIPANTS: The verdicts from the national database of the Taiwan judicial system that pertained to obstetric departments were reviewed. Between 2003 and 2012, a total of 79 closed medical claims were included. MAIN OUTCOME MEASURES: The epidemiologic data of litigations including the results of adjudication and the disease and outcome of the alleged injury. RESULTS: A majority of the disputes (65.9%) were fetus-related. Four disease categories accounted for 78.5% of all claims including (i) perinatal maternal complications (25.3%); (ii) errors in antenatal screening or ultrasound diagnoses (21.5%); (iii) fetal hypoxemic-ischemia encephalopathy (16.5%); and (iv) brachial plexus injury (15.2%). Six cases (7.6%) resulted in an indemnity payment with a mean amount of $109 205. Fifty-one cases (64.6%) were closed in the district court. The mean incident-to-litigation closure time was 52.9 ± 29.3 months. All cases with indemnity payments were deemed negligent or were at least determined to be controversial by a medical appraisal, while all defendants whose care was judged as appropriate by a medical appraisal won their lawsuits. CONCLUSIONS: Almost 93% of clinicians win their cases but spend 4.5 years waiting for final adjudication. The court ruled against the clinician only if there was no appropriate response during a complication or if there was no follow-up or further testing for potential critical diseases.

Characteristics and Risk Factors of Out-of-Hospital Cardiac Arrest Within 72 Hours After Discharge.

OBJECTIVE: To determine the characteristics and risk factors for patients who developed out-of-hospital cardiac arrest (OHCA) within 72 hours after emergency department (ED) discharge. METHODS: A nested case-control study (1:4 ratio) was conducted in 5 EDs from January 2002 to December 2011. The study group consisted of adults experiencing nontraumatic OHCA who revisited ED within 72 hours after discharge. Patients matched in sex, age group and chief complaints were selected for the control group. Demographic data, discharge diagnosis, discharge vital signs and laboratory result were collected. Etiologies of cardiac arrest and whether the events were expected or related to the 1st ED visit were reviewed. RESULTS: In all, 1,657,870 patients were discharged during the study period; 109 developed OHCA within 72 hours of ED discharge (6.6/100,000 per year). The mean age was 64.7 years and 67.9% were men. After comparison with the control group, a higher heart rate (88.5 ± 18.23 versus 81.7 ± 15.93 beat per minutes, P = 0.003) and higher serum creatinine level (2.2 ± 2.30 versus 1.4 ± 1.38 mg/dL, P = 0.002) remain the statistical significant characteristics of study group by conditional logistic regression. Approximately 60% events were expected or unrelated to the 1st ED visit. Among patients whose OHCA were unexpected and related to the 1st ED visit, 71.4% had a cardiac cause. Of these, 20% had chest pain, but 40% had angina-equivalent symptoms during 1st presentation. CONCLUSIONS: A higher discharge heart rate and higher creatinine level are risk factors in these patients.

Factors associated with delayed recognition of pulmonary tuberculosis in emergency departments in Taiwan.

OBJECTIVE: To identify and evaluate factors associated with delayed recognition of pulmonary tuberculosis (TB) in the emergency department (ED). BACKGROUND: Delayed recognition of pulmonary TB in ED may precipitate mortality and morbidity. METHODS: Medical records of newly diagnosed TB patients admitted to four hospitals in Taiwan were retrospectively reviewed. Patients were divided into two groups based on ED physicians' recognition or not of TB and statistically compared to identify differences in their characteristics. RESULTS: 310 newly diagnosed TB patients were identified; 150 were unrecognized in the ED. Cough, chest tightness, general malaise, and body weight loss were more common for those with recognized TB. Older age (≥65 yrs, P = 0.035) and chronic renal insufficiency (P = 0.005) were associated with delayed TB recognition. CONCLUSION: Older age and chronic renal insufficiency are risk factors for delayed TB while in the ED. Typical symptoms should heighten alertness for recognizing TB.