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Quality Improvement & Patient Safety Section Newsletter - June 2010, Vol 11, #3

Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Letter
circle_arrow Editor’s Note – QIPS Resident Quality Award
circle_arrow A Summit Exploring Emergency Department Intake Strategies
circle_arrow First and second quarter-GONE! What’s Next? 
circle_arrow QIPS TIPS “Baby Steps”
circle_arrow A Safe Culture in the Emergency Department (Part 2)
circle_arrow Make A Difference: Write That Council Resolution
circle_arrow Quality and Safety Articles

Newsletter Index

Quality Improvement & Patient Safety Section

The Chair’s Letter

Elaine Thallner, MD, MS, FACEP

Elaine ThallnerI recently attended a seminar at Cleveland Clinic on Empathy and Innovation in Patient Experience.  Empathy is 'the capacity to know emotionally what another is experiencing from within the frame of reference of that other person, the capacity to sample the feelings of another or to put one's self in another's shoes (DM Berger)’.  Many leaders in healthcare and other industries spoke about what their businesses are striving for in terms of customer (or patient) experience.  The consistent messages across the industries represented were that they each had developed metrics around customer experience, understood what their customers needed, had established clear expectations for their employees, and either had in place or were developing reward and recognition programs. 

Chris Caracci from Disney offered lessons on making the purpose of the organization clear to everyone and allowing employees to put “purpose over task".  He gave an example of an employee who had the job of sweeping the walkways.  A visitor asked him to take a photo of his family and the employee did so without hesitation (even though his task was to sweep the walkway, his purpose was to do what the customer needed to have a happy experience).  He also stressed the importance of taking an active role in designing the desired culture.  He said that without attention, most cultures will default towards the negative (this state requires less mental energy). 

Almost universally discussed was the need to hire for 'attitude' and a good cultural fit. All participants spoke about the importance of teamwork, respect, and collaboration. The correlation between employee satisfaction and customer satisfaction has a coefficient of 0.89.  Healthcare units with higher levels of employee engagement have less errors and lower staff turnover.   

This reminds me of the link between 'evidence based leadership' and success with managing change.  Empathy towards our patients and their families is important, but not to be discounted is empathy towards the people with whom we work.  By setting the expectations and goals about our organization's culture, hiring for 'attitude', measuring experience, and being willing to make changes with the goal of excellence in service, we will achieve not only improved quality metrics, but also secondary objectives of increased employee engagement, improved safety culture, and a reduction in staff turnover. 

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Editor’s Note – QIPS Resident Quality Award

Heather Farley, MD, FACEP

Heather FarleyOur section has now established an annual QIPS Resident Quality Award! Graduating resident emergency physicians who demonstrate excellence in, and a passion for quality improvement are eligible for the award.   Nominations for this year’s award were solicited from program directors across the country.  Submitted projects will be judged on their overall importance, innovation, approach and applicability to the general ED community. Award recipients will be recognized at the QIPS Annual Meeting at ACEP Scientific Assembly.  Additionally, a brief synopsis of the recipient's work will be published in our QIPS Section Newsletter.   

We look forward to reviewing the applications and offering recognition for quality improvement work. 


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A Summit Exploring Emergency Department Intake Strategies

Dickson Cheung, MD MBA MPH

Dr. Dickson CheungOn February 25-26 of 2010, a unique conference entitled “A Summit Exploring Emergency Department Intake Strategies” took place in Salt Lake City. This landmark summit, funded by a small conference grant from AHRQ, brought together ED leaders, policy makers and innovators to discuss best practices on how we receive patients into the ED. A prior, related AHRQ conference organized by Brent Asplin and Jesse Pines took a more global approach to quality entitled "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach." For a summary of the Boston conference preceding the 2009 ACEP Scientific Assembly, click on the AHRQ Boston Quality Conference link from QIPS newsletter #2.

The meeting in Salt Lake City was pure nirvana for those of us addicted to ED operations. It consisted of several components: a series of informational and inspirational talks, short presentations on innovative best practices, and a face-to-face working session to complete a formal white paper. In the spring of 2009, an outreach program to various emergency medicine and quality improvement organizations was conducted to identify thought leaders in the area of ED intake. Through a series of conference calls, ED experts and leaders were divided into 3 workgroups to craft a comprehensive whitepaper dealing with specific aspects of the intake process. A steering committee also sought out unique and innovative solutions for greeting the growing numbers of patients arriving to emergency departments. The search produced more than 30 novel concepts, and the best of these Innovators were showcased through poster presentations and brief vignettes at the summit. Additionally, nationally prominent speakers were recruited to frame the issue of ED intake from historical reasons for triage to present challenges; and perspectives from CMS, NQF, and emergency medicine as a specialty. Below you’ll find a brief summary of the talks from my biased but hopefully entertaining viewpoint. 

Charles Reese and Shari Welch began the conference by outlining a case for the importance of new intake strategies. Efficient operations are receiving a lot of attention mainly due to the issues of crowding, capacity, and the resulting need for flow. Funding and regulatory institutions, e.g. CMS and TJC are also intensely focused on these issues leading to a number of NQF-approved performance measures on cycle time management, e.g. length of visit and its components. The marketplace (or as Shari puts it “the dirty capitalist pigs”) are invested because diversion, wait times and patient satisfaction all directly translate into the almighty dollar. From a more altruistic perspective, improved flow could result in higher quality and a safer environment. 

Next up, James Augustine presented a historical perspective of triage and how it continues to create challenges. Our present problem lies partly in the success of emergency medicine in that patients are arriving at our doors faster than we can traditionally process them. Moreover, unprecedented and additive burdens of EMTALA, inadequate revenues (leading to the practice of a “wallet biopsy”) and risk management are forcing EM to develop new models for intake. 

Brent Asplin then encouraged us all to stop thinking of the problem of crowding and start inventing solutions to improve flow. He spent some time talking about “how do you know this ED is [over]crowded?” including some ED workload scales in use or development. He argued that absolute length of stay may not be the best indicator of patient flow but rather a deviation from what is “optimal” or “expected.” Specifically, he presented a time series model for predicting and assessing flow. How long does it take a certain group, i.e. cohort of patients through the system? In contrast to strict LOS measures, this approach has the advantage of adjusting for case-mix of patients as well as predicting capacity in near real-time. 

Next, a series of “viewpoints” were presented from leading organizations with a stake in ED intake. Michael Rapp, CMS director of the quality measurement health assessment group, spoke on the present and future state of CMS quality measures affecting EDs. As an aside, the talk was broadcasted via Skype. Nice trick to have up your sleeve if you want to produce a teleconference without sophisticated resources. Anyway, the concept of value based purchasing is transforming Medicare from a “passive player to an active purchaser of higher quality, more efficient health care.” To this end, CMS created RHQDAPU (pronounced rack-da-poo) which stands for Reporting Hospital Quality Data for Annual Payment Update Program; and admittedly, the worst acronym he has ever come across. This is the 2% incentive to IPPS hospitals to report quality data. He gave examples of how the current core measures (e.g. PNA, AMI, etc) have moved the bar in terms of performance over the years. He then commented on the progress of the 2007 NQF-approved ED throughput measures for incorporation into the IPPS payment guidelines. Early pilot testing of the measures reveal that many EDs would be unprepared to report throughput measures if implemented today (e.g. 48% of EDs cannot determine median time from admit decision time to ED departure time). Thus, more work still needs to be done prior to incorporation of these throughput measures; preferably, via an electronic health record. 

Nick Jouriles, recent past president of ACEP, discussed the importance of intake from the viewpoint of EM as a specialty. He noted that in the past, hospital admissions did not come from the ED; so, intake was not an issue. Now, about 50% of all hospital admissions come through the ED. The evolution of the ED as the “front door” of the hospital will continue to increase its volume, acuity, admission rate and focus on performance and service. 

Suzanne Stone-Griffith, co-chair of the last two NQF committees on ED measures, then presented the history and growing importance of this voluntary consensus standards-setting organization. She described the entire process of how a quality measure gets developed, endorsed, implemented and maintained. And the growing coordination between TJC, CMS, NQF, CSAC, PQRI, AQA and the HQA (alphabet soup, I tell ya). As such, NQF-approved measures will increasingly become the “Good Housekeeping Seal of Approval” for healthcare performance measures. Very educational. I was surprised how much I did not know about how these quality measures are enacted akin to how “bills gets made into laws.” This may make a good newsletter article in the future. 

Ellen Weber, who spent a sabbatical studying the 2004 implementation of the four hour ED stay mandate in the United Kingdom, then gave an enlightening account of how the National Health Services tackled this issue of ED intake across the pond. From a leadership perspective, I was shocked by how boldly the plan was enacted. For better or worse, once the mandate passed, hospitals were forced to take it seriously. CEOs were immediately dismissed for noncompliance and large monetary rewards were handed out for meeting annual targets. From a processing perspective, the triage scheme is greatly simplified. There is a greater reliance on the judgment of experienced practitioners, greater flexibility to do different things depending on circumstances and a greater reliance on pathways and protocols. Patients are divided into two simple categories: the “majors” and the “minors.” The “majors” receive immediate “pit stop” assessments by a senior RN and MD to begin diagnostics and treatments. The “minors” (about 50-60% of patients) do not receive a traditional full triage assessment as we currently practice in the US today unless there is a delay in care. In other words, if the medical condition or injury was “minor,” the MD or NP may just “see and treat” the patient without any nursing intervention. Imagine that! 

Along these lines, Jody Crane presented how we need to start thinking of segmenting or streaming patients in a more sophisticated manner. After some background on queuing theory, Lean methodology and triage systems (ESI, NTS, CTAS), he talked about the pitfalls of under-segmentation (too few paths) and over-segmentation (too many paths). In relation to our current ESI triage system, he argued that the ESI 1-2 and the ESI 4-5 patients are fairly easy to segment. It is the ESI 3 patients that present the greatest challenge because looking for the ESI 3 patient with a real emergency medical condition is like trying to find a “needle in a haystack.” In addition, he mentioned that the need for segmentation is dependent on the volume of the ED, i.e. the higher the volume, the greater the need for segmentation and streaming strategies. 

Ted Chan then presented a potpourri of technological tools that may aid in the challenge of intake. Specifically, he described the evolution of information technology systems (e.g. HIS/EDIS systems, EMS data, the Google “cloud”, smart cards, etc.), biometric identification technologies (iris scanning, palm vein authentification, face recognition, etc), patient tracking systems (e.g. bar coding, RFID, etc.) and communication systems (e.g. pagers, cell phones, walkie-talkies, wireless monitoring). 

Next, James Adams gave a refreshing talk on the role of leadership and ED operations. He spoke of balancing the competing (and, often mixed) messages of improving efficiency, better service and increasing capacity. The talk was peppered with sage advice on how to motivate and lead staff including “listen until you hear others say the right thing and then positively reinforce the idea or behavior.” 

Finally, Sally Phillips presented disasters as the ultimate test of ED intake. She described her work at AHRQ on bioterrorism, blackouts, natural disasters and other multi-casualty events. All I could think about during her talk about ED surge capacity in such an event is “if a catastrophe happens, we’re screwed.” 

Most of the latter part of the afternoon was devoted to the Innovators who have succeeded at trying something new to improve the intake process. Due to space limitations, I’ll just briefly list the title of the presentations and their associated institutions: 

  1. Supplemented Triage and Rapid Treatment (START): A Proposed Model for Patient Intake and Flow in the emergency Department (Massachusetts General Hospital)
  2. Rapid Medical Evaluation Success with Provider in Triage in High Volume Urban, Public, Teaching Hospital (Arrowhead Regional Medical Center)
  3. Utilization of a Low Flow/High Flow State to Decrease Door to Provider Time (Thomas Jefferson University Hospital)
  4. Palm Vein Scanning to Improve Door to Physician Times (Carolinas Medical Center)
  5. Physician First (St Rose)
  6. Telemedicine in the Emergency Department (Georgia Partnership for TeleHealth)
  7. Super Track: A Lean Based Approach (Christiana Care Health System)
  8. The Philadelphia Prehospital Admission Rule (University of Pennsylvania)
  9. Door to Doc in the Emergency Department (Banner Health Corporation)
  10. Implementation of Physician in Triage (Memorial Hospital, York PA)
  11. Priority One: ED-ICU Admission Facilitation (Intermountain Medical Center)

The first day ended with a dinner and discussion with the legendary Brent James, medical director at Intermountain Healthcare. The beginning of his talk was a bit technical as he described the history of various quality initiatives at Intermountain. All the charts and graphs of various medical conditions transported me back to my stats and epidemiology classes. As the evening wore on, the conversation got more interesting as he shared his candid philosophies on how to change an organization. Specifically, he described the inferiority of the approach of Taylor (top-down) to Deming (bottom-up). Moreover, the differences between lording “power over” employees and giving staff the “power to” improve outcomes. 

The bulk of the second and final day was devoted to workgroup reports focusing on three critical issues. In the near future, look for a formal white paper to be published addressing: 

  1. Identification of Constraints to Intake
  2. Solutions to Common Intake Problems
  3. Measurements and Definitions of Intake

Attendees were impressed by the innovator presentations, enthusiastic in the discussions that took place, and optimistic that practice strategies identified through the process would be applied through the country. A special thanks to Shari Welch (along with the Emergency Department Benchmarking Alliance and the Intermountain Institute for Health Care Delivery Research) for hosting the conference. The EDBA and Intermountain have plans to make this beginning of a series of “Salt Lake Summits,” using this successful “bottom up” model to improve multiple aspects of emergency health care. Next up? A followup conference on the “backend” impediments to flow including discharges to home and admissions to the hospital. 

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First and second quarter-GONE! What’s Next?

Andrew I. Bern, MD, FACEP
Board Liaison to the Sections Task Force, Critical Care Section, and EMS Section

bernIt is hard to imagine that we are already entering the seventh month of this activity year.  If you were the CEO of a corporation preparing your stockholders report of your first two quarters where corporate leadership is analogous to section leadership and your stockholders are your section members, how did you do?  For a stockholder, one's return on investment is the measurement of success.  For sections, success is measured by a return of value to the membership. This can take the form of section strategic planning, the development of a communication’s plan, and a focus of activity in projects including submission of a letter of intent to the section grant task force for this year's grants. Does everyone in your section have a clear focus on what is to be accomplished this year? Has a section produced two newsletters to date? Have you engage your section members with your section’s website and your e-list?  Has your section provided the opportunities for professional development and leadership development for your section members? Have you promoted the committee interest forms to your members? And, what of advocacy?  Have you promoted the leadership and advocacy conference in Washington DC to your members? This is an excellent opportunity for all section leaders to get together and identified midcourse corrections in your strategic plan as well as to have your councillors and alternate councillors get to meet councillors from other chapters and sections. It is an opportunity to become engaged, receive media training, and fully participate in the advocacy efforts of the college. 

We were now heading towards the political season of our activity year. Not only are we focused on advocacy in Washington DC during the Leadership and Advocacy Conference, but we are also looking at the College and its direction and our ability to affect that direction through the development of resolutions that will be submitted through June of this year.  The resolution process is a direct connection between the membership and the College leadership. 

It is the democratic process by which the membership can help focus the College and directions that matter most to them and their patients.  At its April 13-14 meeting, the ACEP Board of Directors heard recommendations from the Nominations Committee for who will be candidates for the Board of Directors.  The speaker will also notify all councillors who have an interest in serving as Council officers, Reference Committee chairs, and members of the Steering Committee to provide feedback to him. It is important for sections to be energized and to encourage current councillors, alternate councillors, and interested members to attend the Council meeting in Las Vegas prior to the start of the Scientific Assembly. 

It is also important for section leadership to begin planning for their Scientific Assembly annual meetings, strategic planning, and develop plans to expand and increase membership.  For some, this will mean increased attention and collaboration with EMRA. 

Sections can be nimble and responsive to the membership.  This makes sections a real grassroots operation with the ability to take on projects and tasks driven by the membership. 

In just a short time, best practices amongst the sections have produced textbooks, white papers, award-winning newsletters, and the expansion of knowledge in many areas. 

What will your section due to expand the opportunities for your membership and the knowledge base of emergency medicine?  Only your section can provide these answers. 

We are all waiting to see what you produce.  The ACEP Board of Directors and I look forward to support you and recognize your efforts.


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QIPS TIPS “Baby Steps”

Shari Welch, MD, FACEP

Shari WelchAdverse events occur in 4% of all healthcare encounters.  Twenty per cent of these will be medication errors.  Some estimate that medication errors in the fast paced uncontrolled ED environment occur in 3% of ED visits.  Pediatric medication errors occur twenty times more frequently than adult medication errors!  “Houston, we’ve got a problem!” 

The features of pediatric medication administration that set up for this increase in error are easy to recognize: 

  1. Extreme variation in dosing;
  2. Variation in preparations (ie: 100mgs/5 mls, 250 mgs/5ml);
  3. Dosing does not become “familiar” to physicians or nurses;
  4. Difficulty recognizing  the errors (non-verbal patients); and
  5. The pounds/kilograms confusion.

One of the most common root causes of medication errors deals with scale functions and is easily remedied.  Most pediatric scales used in healthcare can be set to read in pounds or kilograms.  The typical scenario for an error to occur is this:  An infant or toddler is weighed in kilograms and the loving parents query “What is that in pounds?”  The nurse flips the scale to the pound mode for the parents to see and then takes the baby to a room for evaluation.  Unwittingly the next child is weighed in pounds but it is recorded as kilograms.  That child gets twice the medication dose it needs.  Except at pediatric hospitals where over time the nurse may be able to eyeball weights and doses, the typical ED Nurse and physician are never familiar enough to catch such mistakes at a glance. 

Is there a simple solution?   Disable the scale so it can’t read pounds.  Have your equipment engineers do this for you if it is not apparent how to go about disabling it.  Sometimes it is as simple as putting duck tape such that the pounds weight reading is disabled.  Interested parents can be given a weight card that shows the conversion between pounds and kilograms.  They can be encouraged to take it with them for home medication administration. 

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A Safe Culture in the Emergency Department (Part 2)

Mark T. Fleming and Pat Croskerry      

Excerpted with permission from Croskerry, P., Cosby K.S., Schenkel, S.M, and Wears, R.L. Patient Safety in Emergency Medicine. Philadelphia: Lippincott Williams and Wilkins, 2009.

  StephenSchenkel0510 PatCroskerry0510
Dr. Stephen Schenkel     Dr. Pat Croskerry

The first section of this chapter was published in the previous QIPS newsletter.No photograph is available for Dr. Fleming.

Characteristics of a Safe Culture

In order to promote a safe culture, there is a need to identify the organizational practices associated with a safe culture. 

Commitment, Competence, and Cognizance

Reason (18, 19) discusses three cultural factors that play roles in an organization’s progress toward greater safety: commitment, competence, and cognizance.  These have been recognized as being central to the development of successful safety practices (20).  Commitment, competence, and cognizance are shaped by the quality of the decision making made at the top level of a health care organization (18).  

Commitment has two elements: motivation and resources.  Motivation is related to whether the health care organization attempts to be a true safety leader or merely tries to avoid litigation and scrutiny by regulatory or professional bodies.  The commitment of resources relates to the organization’s allocation of funding, as well as human resources, in the pursuit of safety goals.  Being committed to achieving goals is futile if an ED does not have the capacity to achieve the goals set. 

The safety culture of an ED is reflected in the organization’s approach toward safety information technology and its ability to adequately collect safety information, distribute it, and respond to it.  The quality of the resources allocated is just as important as the quantity of resources.  Finally, cognizant EDs recognize that safety is an ongoing struggle.  They seek to reform and proactively strengthen their safety defenses during lengthy periods without a bad incident.  They avoid complacency even when things appear to be going well (19). 

High Reliability Organizations

High reliability organizations constantly operate under high-risk conditions but have few failures.  Examples of such organizations include air traffic control systems, nuclear power generating plants, and aircraft carriers (21).  These organizations carry out a range of extraordinary steps toward their goals of incident-free performance (22).  High reliability organizations are not error-free, but when errors do occur, their effects are contained so they do not turn into major failures.  Invariably, these organizations have strategies to respond to unexpected events (22). 

High reliability organizations are expert in making fast decisions based on imperfect data and knowing when to improvise instead of follow routines (23). 

There are parallels between the challenges faced by EDs and HROs, such as dealing with ambiguity, rapid changes in tempo, and around-the-clock operations.  It seems reasonable that EDs might learn from some of the organizational safety practices adopted by HROs. 

High reliability organizations have a preoccupation with failure, treating any lapse as an indication that something is wrong with the system.  They encourage employees to report errors.  High reliability organizations are reluctant to simplify, preferring a complete picture of what is going on.  Anomalies in the system are noticed while they can still be isolated.  Front-line workers are expected to notice and respond to systems problems.  High reliability organizations are committed to resilience, developing capabilities to detect, contain, and rebound from errors that inevitably occur.  They allow authority to migrate to the employees with the most expertise, regardless of their level of seniority (21). 

Barriers to Creating a Safer Emergency Department Culture

Listing the features of a safe culture is relatively easy compared with trying to implement the required culture change.  Five barriers to achieving safer health care have been described (24): 

  1. No limits in production;
  2. Excessive autonomy;
  3. Craftsman’s attitude;
  4. Ego-centered safety protection; and
  5. Loss of visibility of risk.

Overcoming these barriers is fundamentally a cultural challenge.  They can be used to map out a cultural improvement strategy. 

No Limits in Production

Excessive production demands seem to typify EDs, as it is not possible to limit workload via the administrative or physical controls typical of other care areas.  Neither staffing ratios nor number of beds will work.  This lack of limits leads to overcrowding and excessive wait times.  To an extent, coping with surges in demand is an inherent feature of EDs.  Emergencies by their nature are unpredictable, and patients need immediate treatment, but persistent overcrowding is a symptom of system problems.  The Joint Commission recently concluded that 31% of sentinel events that occur in EDs are caused in part by overcrowding (25).  In the United States, the National Ambulatory Medical Care Survey (26) reports that more than 10% of emergent cases wait over an hour to be seen by a physician. 

The idea that “the ED is the only infinitely expansible part of the hospital” (9) can do harm.  The willingness of emergency physicians to try to cope with just about anything may not always be a virtue.  Instead, it may have become part of the problem.  Although in many EDs overcrowding is chronic, it is important not to normalize this situation, but to identify it as a patient safety failure that can contribute to adverse events.  The alternative—to allow this deviance and its associated practices to become the norm—alters the underlying culture.  New members of the practice learn responses to overcrowded and unsafe conditions as an acceptable norm.  As a consequence, the underlying danger—overcrowding—continues unaddressed (9). 

Emergency departments need to review the impact overcrowding has on the delivery of care and identify potential deviations that reduce safety margins.  Acknowledgement of the problem is a first step. 

Given that surges are chronic in many EDs, additional resources should be allocated to cope with additional demand.  Emergency department resource allocation is usually outside the control of the department, as EDs compete with other departments.  It is often a political decision, influenced by public opinion.  In some national health care systems, elective procedure wait times carry more political importance than ED overcrowding, especially when wait times may be on the order of months rather than hours. 

Excessive Autonomy

Increasing use of team-based training and specific care protocols, both of which limit caregiver treatment variance, illustrate a willingness to accept less autonomy (24).  Still, there is a long way to go.  Boreham et al. (27) conducted a comprehensive analysis of latent conditions contributing to errors in two EDs in the United Kingdom.  They identified the strict horizontal and vertical divisions in the organization of staff as critical latent factors.  This suggests that EDs could improve patient safety by increasing teamwork and breaking down barriers between disciplines and levels of seniority.  In HROs the person with the greatest expertise in the situation takes charge irrespective of their level of seniority or discipline.  In health care there are significant practical, legal, and cultural barriers to adopting this approach, but greater recognition of expertise of team members and more team training will assist in breaking down barriers. 

There is also a need to reduce the autonomy of individual departments and units, as they often consider only their own interests and not the impact on other departments. For example, ED overcrowding caused by admitted patients boarding in the ED due, in turn, to a lack of beds in receiving wards, is viewed as an ED problem as opposed to a hospital problem (28).  Clearly, moving the admitted patient up to a department that is already full causes problems for that department, but it may be the best solution for the patient.  Several hospitals in the United States have implemented a “full capacity protocol”, which allows admitted patients from the ED to be moved to the receiving ward even when the receiving ward is full.  This approach is based on the recognition that ED overcrowding is a hospital problem and therefore all units can share the overcrowding load.  Implementing the full capacity protocol involves breaking down department boundaries by focusing on patient care rather than departmental priorities. 

Craftsman’s Attitude

One of the attractive features of a piece of handcrafted furniture is that it is unique.  This is in contrast to standardized and predictable mass-produced furniture.  The variability created by differences in skill and technique is part of the attraction.  In health care, domains that promote the individual skill of the provider, such as surgery, are associated with poorer outcomes than those domains, such as anesthesiology, that have standardized practices (24).  Essentially, anesthesiologists deliver a consistent level of care.  They are functionally equivalent to each other, so that changing the professional does not significantly change the approach or the outcome. 

The benefits of standardizing practice are evident through the results of specific patient safety improvement interventions, for example, the 100,000 Lives campaign in the United States and Safer Health Care Now! in Canada. 

These interventions have demonstrated that physicians are willing to accept restrictions placed on their professional autonomy when they are supported by evidence of effectiveness.  To a large extent, emergency physicians operate as functional equivalents, as patients accept whoever is available rather than selecting a specific doctor, but further standardization is likely to increase patient safety.

In the ED, this could be achieved through the development and implementation of more standardized, evidence-based approaches to care. 

Ego-Centered Safety Protection

Learning from incidents is one of the key attributes of HROs.  The fear of litigation or disciplinary action following an adverse event can limit learning, as the focus is usually on avoiding blame rather than fixing the problem (19).  The immediate cause of an adverse event in the ED has often been attributed to the action or inaction of a health care worker, even though the underlying cause may be a systemic problem.  For example, a patient being “boarded” in the ED might deteriorate and suffer an adverse event because insufficient attention was being paid to him or her.  The proximal cause is the inaction of the person who should have been monitoring the patient, and this is likely to attract substantial attention.  But the distal cause is a systemic one of overcrowding.  The person whose inaction contributed to the adverse event is likely to be reluctant to report this injury, as he or she was partially responsible and may suffer as a result.  If the adverse event results in litigation or negative media attention, then the person closest to the incident is an easy scapegoat.  As a result, the tricky challenge of overcrowding does not receive appropriate attention. 

To avoid ego-centered safety protection, EDs need to identify systemic failures routinely.  Regular identification of system failures that reduce safety margins without linking them directly to specific incidents of patient harm increases the likelihood that action will be taken.  At a minimum, documentation of system flaws provides protection for the innocent against being offered up as scapegoats when something bad happens. 

Loss of Visibility of Risk

Infrequent adverse outcomes make it difficult to identify evidence-based interventions.  Each event often has multiple causal factors.  In addition, the lack of data makes identification of common causes difficult.  A single adverse event often leads to the introduction of new rules and regulations without evidence, necessarily, of their effectiveness (24).  Interventions may prevent a recurrence of the specific event, but, in total, actually reduce safety margins.  Excessive rules can limit action to such an extent that it is no longer possible to perform effectively (19).  The growing political attention on patient safety increases the potential application of reactionary rules and regulations.  The development of valid indicators of patient safety within the ED is necessary to provide meaningful information on system safety. 

Initiative To Improve the Emergency Department Culture

  • Promote greater insight among ED staff into the inherent vulnerability of patients who seek care in the ED.
  • Promote general acceptance within the health care system that the ED has unique operating characteristics and needs that require special consideration and resources.
  • Show that limited resources and excessive production demands reduce safety margins.
  • Document unsafe practices associated with excessive product production demand.
  • Implement team training that promotes the capabilities of each discipline and breaks down horizontal and vertical barriers.
  • Do not accept sole responsibility for hospital or health care system problems.
  • Promote better understanding and collaboration between departments.
  • Continue to develop and implement best practice protocols.


  • Emergency medicine has a number of special attributes that make it a unique culture within medicine.  Every ED has its own micro culture.
  • A proposed model of culture describes three levels with progressively increasing visibility: basic assumptions, espoused values, and artifacts.
  • The prevailing culture of an ED strongly impacts patient safety.
  • Three major cultural factors play critical roles in establishing and maintaining a safe culture: commitment, competence, and cognizance.
  • Several known barriers may prevail against the development of a safe culture.
  • Specific initiatives may be taken to improve safety in the ED.




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Make A Difference: Write That Council Resolution

ACEP is a living entity, which needs new ideas to keep it healthy and viable in the 21st century. Many College members introduce new ideas and current issues to ACEP through Council resolutions. This may sound daunting to our newer members, but the good news is that only takes two ACEP members to submit a resolution for Council consideration. In just a few months the ACEP Council will meet and consider numerous resolutions.

ACEP’s Representative Council, the major governing body for the College, considers resolutions annually in conjunction with Scientific Assembly. During this annual meeting, the Council considers many resolutions, ranging from College regulations to major policy initiatives thus directing fund allocation. For 2010, the Council has 330 Councillors: ACEP members representing chapters, sections, EMRA, and AACEM.

This Council meeting is your opportunity to make a resounding impact by setting our agenda for the coming years. Topics such as the direct election of the president-elect, or working with the Emergency Nurses’ Association on staffing models, grew directly from member resolutions submitted to the Council. If you have a hot topic that you believe the College should address, now is the time to start writing that resolution.

I’m ready to write my resolution

Resolutions consist of a descriptive Title, a Whereas section, and finally, the Resolved section. The Council only considers the Resolved when it votes, and the Resolved is what the Board of Directors reviews to direct College resources. The Whereas section is the background, and explains the logic of your Resolved. This should be short, focus on the facts, and include any available statistics. The Resolved section should be direct and include recommended action, such as a new policy or action by the College.

There are two types of resolutions: general resolutions and Bylaws resolutions. General resolutions require a simple majority vote to pass, while Bylaws resolutions require a two-thirds majority. When writing Bylaws resolutions, list the Article number and Section from the Bylaws you wish to alter. Then, in the resolution, you should show the current language, and bold your suggested new language while striking through the suggested edits. See the ACEP Web site article, “Guidelines for Writing Resolutions,” which further details the process and offers tips on writing a resolution.

I want to submit my resolution

It takes at least two members to submit a resolution, or a Chapter or Section may submit a resolution. If the resolution comes from a Chapter or Section, then a letter of support from the President of the Chapter or Chair of the Section is required. The Board of Directors or an ACEP committee can also submit a resolution. The Board of Directors must review any resolution from an ACEP committee, and usually reviews all drafts at their June meeting. Bylaws resolutions pass through the Bylaws committee for review and suggested changes. These changes and suggestions are referred back to the author of the resolution for consideration. One may submit a resolution by mail, fax, or email. Resolutions are due at least 90 days before the Council meeting. This year the deadline is June 29, 2010.

Debating the resolution

Councillors receive the resolutions prior to the annual meeting along with background information from ACEP staff. Discussion often occurs on the Council electronic list serve prior to the Council meeting. At the discretion of the Speaker, non-Councillor resolution authors may be added to the Council e-list serve upon request.

At the Council meeting, the Speaker and Vice-Speaker divide the resolutions into four reference committees. The reference committees meet and hear testimony on each resolution. You, as the author of your resolution, should attend the reference committee that discusses your resolution. Reference committees allow for open debate and unlimited testimony, and participants often have questions best answered by the author. Afterwards, the reference committee summarizes the debate and makes a recommendation to the Council.

The Council then meets to discuss all the resolutions. Each reference committee presents each resolution, providing a recommendation and summary of the debate to the Council in writing and on the podium, and then the Council debates each resolution. Any ACEP member may sit in the back and listen to the Council debate whether a Councillor or not. If you wish to speak directly to the Council, you may request to do so in writing to the Speaker before the debate. Include your name, organization affiliation, issue to address, and the rationale for speaking to the Council. Alternatively, you may ask your Chapter or Section for alternate Councillor status and permission for Council floor access during debate. Chapters and Sections often have alternate Councillor slots and encourage the extra participation.

The Council’s options are: Adopt the resolution as written; Adopt as Amended by the Council; Refer to the Board, the Council Steering Committee, or the Bylaws Interpretation Committee; Not Adopt (defeat or reject) the resolution; or Postpone.

Hints from Successful Resolution Authors

  • Present your resolution prior to submission to your Chapter or Section for sponsorship on the Council floor. This way, they can give advice and assistance.
  • Consider the practical applications of your resolution. A well-written resolution that speaks to an important issue in a practical way passes through the Council much more easily.
  • Do a little homework before submitting your resolution. The ACEP web site is a great place to start. Does ACEP already have a policy on this topic? Has the Council considered this before? What happened?
  • Find and contact the other stakeholders for your topic. They have valuable insight and expertise. Those stakeholders may co-sponsor your resolution.
  • Attend debate concerning your resolution in both reference committee and before the Council. If you cannot attend, prepare another ACEP member to represent you.

I need more resources

Go to ACEP’s Web site, Pick the “Member Center” drop list, then “Leadership,” and click on “Council.” There you will see a link to the “Guidelines for Writing Resolutions” article. All authors should review this article prior to writing their resolution. Additionally, there is information about the Council Standing Rules, Council committees, and Councillor/Alternate Councillor job descriptions. Of special note, there is a link to Action on Past Resolutions. Under this link are .pdf documents dating back to 1998 summarizing each resolution and what has occurred with each of them. You can review past actions, or keep track of what happens once your resolution passes.

Well, get to it

Writing and submitting Council resolutions keeps our College healthy and vital. A Council resolution is a great way for College members to speak to the leaders of the College and the Board of Directors. Even if your resolution does not pass, the College will debate the topic and consider its ramifications. Additionally, other members may have resources or suggestions to address your issue. I encourage you to take advantage of this opportunity and exercise your rights as part of our Emergency Medicine community. Dare to make a difference by submitting a resolution to the ACEP Council.


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Quality and Safety Articles 

Helmut Meisl, MD, FACEP

meislHere again is a list of recent articles for your interest. These are compiled by AHRQ PSNet at (

  • The relationship between organizational leadership for safety and learning from patient safety events.
    Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010 Mar 10. 
  • Time to listen: a review of methods to solicit patient reports of adverse events.
    King A, Daniels J, Lim J, Cochrane DD, Taylor A, Ansermino JM. Qual Saf Health Care. 2010;19:148-157.
  • Malpractice reform—opportunities for leadership by health care institutions and liability insurers.
    Mello MM, Gallagher TH. N Engl J Med. 2010 Mar 31. 
  • Adverse events in hospitals: the patient's point of view.
    Massó Guijarro P, Aranaz Andrés JM, Mira JJ, Perdiguero E, Aibar C. Qual Saf Health Care. 2010;19:144-147.
  • Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial.
    Etchells E, Adhikari NKJ, Cheung C, et al. Qual Saf Health Care. 2010;19:99-102.
  • Using care bundles to reduce in-hospital mortality: quantitative survey.
    Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock K. BMJ. 2010;340:c1234. 
  • Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.
    Burnett S, Benn J, Pinto A, Parand A, Iskander S, Vincent C. Qual Saf Health Care. 2010 Mar 8. 
  • Engaging patients as vigilant partners in safety: a systematic review.
    Schwappach DLB. Med Care Res Rev. 2010;67:119-148. 
  • Triggers for emergency team activation: a multicenter assessment.
    Chen J, Bellomo R, Hillman K, Flabouris A, Finfer S; the MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. J Crit Care. 2010 Feb 26. 
  • The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.
    Guralnick S, Rushton J, Bale JF Jr, Norwood V, Trimm F, Schumacher D. Pediatrics. 2010;125:786-790.
  • Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.
    Pines JM, Mongelluzzo J, Hilton JA, et al. Ann Emerg Med. 2010 Feb 25.
  • Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database.
    Andersen PO, Maaløe R, Andersen HB. Resuscitation. 2010;81:312-316.
  • Identified safety risks with splitting and crushing oral medications.
    Paparella S. J Emerg Nurs. 2010;36:156-158.
  • Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors.
    Kazemi A, Fors UG, Tofighi S, Tessma M, Ellenius J. J Med Internet Res. 2010;12:e5.
  • Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.
    Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
  • ED overcrowding is associated with an increased frequency of medication errors.
    Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.
  • Learning mechanisms to limit medication administration errors.
    Drach-Zahavy A, Pud D. J Adv Nurs. 2010;66:794-805.
  • Can electronic clinical documentation help prevent diagnostic errors?
    Schiff GD, Bates DW. N Engl J Med. 2010;362:1066-1069.
  • Frequency of inappropriate medical exceptions to quality measures.
    Persell SD, Dolan NC, Friesema EM, Thompson JA, Kaiser D, Baker DW. Ann Intern Med. 2010;152:225-231.
  • Effect of point-of-care computer reminders on physician behaviour: a systematic review.
    Shojania KG, Jennings A, Mayhew A, Ramsay C, Eccles M, Grimshaw J. CMAJ. 2010 Mar 8.
  • Medication reconciliation and hypertension control.
    Persell SD, Bailey SC, Tang J, Davis TC, Wolf MS. Am J Med. 2010;123:182.e9-182.e15.
  • Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study.
    Braithwaite J, Greenfield D, Westbrook J, et al. Qual Saf Health Care. 2010;19:14-21.
  • Iatrogenic events contributing to ICU admission: a prospective study.
    Mercier E, Giraudeau B, Giniès G, Perrotin D, Dequin PF. Intensive Care Med. 2010 Mar 9. 
  • A comparison of voluntarily reported medication errors in intensive care and general care units.
    Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59. 
  • Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
    Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
  • Medication errors with the dosing of insulin: problems across the continuum.
    PA-PSRS Patient Saf Advis. March 2010;7:9-17. 
  • Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?
    Singh H, Thomas EJ, Sittig DF, et al. Am J Med. 2010;123:238-244.
  • Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.
    Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010 Feb 24. 
  • What doctors can learn from the factory floor.
    Martyn C. BMJ. 2010;340:c1217.
  • Getting it right when things go wrong.
    Pettker CM, Funai EF. JAMA. 2010;303:977-978.
  • Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.
    Apker J, Mallak LA, Applegate EB 3rd, et al. Ann Emerg Med. 2010;55:161-170.
  • Patient safety research: an overview of the global evidence.
    Jha AK, Prasopa-Plaizier N, Larizgoitia I, Bates DW; Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. Qual Saf Health Care. 2010;19:42-47.
  • Measures of patient safety in developing and emerging countries: a review of the literature.
    Carpenter KB, Duevel MA, Lee PW, et al; Methods & Measures Working Group of the WHO World Alliance for Patient Safety. Qual Saf Health Care. 2010;19:48-54.
  • If only...: failed, missed and absent error recovery opportunities in medication errors.
    Habraken MMP, van der Schaaf TW. Qual Saf Health Care. 2010;19:37-41.
  • Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.
    Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309. 
  • Hospital safety climate and safety outcomes: is there a relationship in the VA?
    Rosen AK, Singer S, Zhao S, Shokeen P, Meterko M, Gaba D. Med Care Res Rev. 2010 Feb 5.
  • When the 5 rights go wrong: medication errors from the nursing perspective.
    Jones JH, Treiber L. J Nurs Care Qual. 2010 Feb 16. 
  • Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions.
    Hall LW, Scott SD, Cox KR, et al. Qual Saf Health Care. 2010;19:3-8.
  • The effect of multidisciplinary care teams on intensive care unit mortality.
    Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. Arch Intern Med. 2010;170:369-376. 
  • Clinical and economic outcomes attributable to health care–associated sepsis and pneumonia.
    Eber MR, Laxminarayan R, Perencevich EN, Malani A. Arch Intern Med. 2010;170:347-353. 
  • Does teamwork improve performance in the operating room? A multilevel evaluation.
    Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-142.
  • The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study.
    Sharpe R, Koval V, Ronco JJ, et al. Crit Care Med. 2010;38:766-770.
  • The incidence and nature of prescribing and medication administration errors in paediatric inpatients.
    Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010 Feb 4. 
  • Complications and death at the start of the new academic year: is there a July phenomenon?
    Inaba K, Recinos G, Teixeira PGR, et al. J Trauma. 2010;68:19-22. 
  • Measuring communication in the surgical ICU: better communication equals better care.
    Williams M, Hevelone N, Alban RF, et al. J Am Coll Surg. 2010;210:17-22.
  • Risk managers, physicians, and disclosure of harmful medical errors.
    Loren DJ, Garbutt J, Dunagan WC, et al. Jt Comm J Qual Patient Saf. 2010;36:101-108. 
  • Patient characteristics and the occurrence of never events.
    Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
  • Interns overestimate the effectiveness of their hand-off communication.
    Chang VY, Arora VM, Lev-Ari S, D'Arcy M, Keysar B. Pediatrics. 2010 Feb 8. 
  • Connectivity to improve patient safety.
    Whitehead SF, Goldman JM. Patient Saf Qual Healthcare. January/February 2010;7:26-30.
  • Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.
    Einav Y, Gopher D, Kara I, et al. Chest. 2010;137:443-449. 
  • A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals.
    Mills PD, Watts BV, Miller S, et al. Jt Comm J Qual Patient Saf. 2010;36:87-93.                                                                 
  • Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.
    Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.
  • Team training of medical students in the 21st century: would Flexner approve?
    Morrison G, Goldfarb S, Lanken PN. Acad Med. 2010;85:254-259.  
  • Weekend mortality for emergency admissions. A large, multicentre study.
    Aylin P, Yunus A, Bottle A, Majeed A, Bell D. Qual Saf Health Care. 2010 Jan 28.
  • Parents' medication administration errors: role of dosing instruments and health literacy.
    Yin HS, Mendelsohn AL, Wolf MS, et al. Arch Pediatr Adolesc Med. 2010;164:181-186. 
  • Patient handoffs: standardized and reliable measurement tools remain elusive.
    Patterson ES, Wears RL. Jt Comm J Qual Patient Saf. 2010;36:52-61. 
  • What have we learned about interventions to reduce medical errors?
    Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010 Jan 4.
  • Safe electronic health record use requires a comprehensive monitoring and evaluation framework.
    Sittig DF, Classen DC. JAMA. 2010;303:450-451.
  • Patient safety measures in burn care: do national reporting systems accurately reflect quality of burn care?
    Mandell SP, Robinson EF, Cooper CL, Klein MB, Gibran NS. J Burn Care Res. 2010;31:125-129.
  • Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.
    Santamaria J, Tobin A, Holmes J. Crit Care Med. 2010;38:445-450.
  • Intensive care unit alarms—how many do we need?
    Siebig S, Kuhls S, Imhoff M, Gather U, Schölmerich J, Wrede CE. Crit Care Med. 2010;38:451-456.  
  • Patient safety and diagnostic error: tips for your next shift.
    Sinclair D, Croskerry P. Can Fam Physician. 2010;56:28-30.

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.


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