Presentation at the Health Consumers Council Patient Experience Week Events, by Dr Carmel Crock and Ms Anita Deakin. The Emergency Medicine Events Register is an "adverse event and near-miss reporting system that is peer-led, online, anonymous and confidential. It is a means of supporting improvement in safety and quality in emergency medicine by understanding of contributing factors and how the risk of harm to patients can be minimised or prevented." See http://www.emer.org.au/

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EMER
Emergency Medicine Events Register
“Learning from our errors”
Dr Carmel Crock and Ms Anita Deakin
“Patient Experience Week”
28-29th April, 2016
Perth, Australia

2. Emergency Medicine Events Register
- 2015 London film presentation -
Learning from our errors

3. High Risk/Reliability Organizations and Industries

4. Human Error: Models and Management
“Perhaps the most important distinguishing feature of high
reliability organisations is their collective preoccupation with
the possibility of failure. They expect errors and train their
workforce to recognise and recover from them. They
continually rehearse familiar scenarios of failure and strive
hard to imagine novel ones…Instead of making local
repairs, they look for system reforms.”
Reason BMJ March 2000

5. What is EMER?
 Specialty-specific incident monitoring
 What happens in EDs?
 Why?
 What can we do to prevent these
incidents?

6. Why do things go wrong in an ED?
 Is it our environment?
 Is it our training?
 Is it about how we communicate?

7. Benefits of EMER
 Raise awareness about error and safety
 Create a culture where it is safe to discuss
error/near misses
 Honesty, openness
 Question how we do things
 How could I/we have done better?

8. EMER as a ‘debrief‘ tool
 Forgive ourselves after an error
 Pick ourselves up
 Error and shame –stress/depression
 Effect of an error on whole department

9. Rory Staunton

10. Quality = ......
 Learning from our error
 Communication – both between
healthcare providers/ with patient
 Discharge instructions
 Results checking
 Partnering with patients for quality in EDs
 Healthy workplace/ Mentoring juniors

12. Consumer Reporting
“Complaints from patients and/or their carers are important indicators of
problems in a healthcare system. The patient perspective is important
because users of health services may have a different view of problems
to those reported by health professionals in the adverse incident reporting
systems that are now routine practice in many countries.” [1]
“Integrating patients’ perspective broadens the existing understanding of
adverse events…..” [1]
“Of note, while concerns generated by patients and families most often
did not lead to PSI (patient safety incident) identification, we feel strongly
that their feedback is still highly valuable for understanding and improving
the patient experience” [2]
1
. Lang, S., Garrido, M.V., and Heintze, C. (2016) Patients’ views of adverse events in primary and ambulatory care: a systematic review to assess methods and the
content of what patients consider to be adverse events. BMC Family Practice. 17:6
2
. Reznek, M.A., Kotkowski, K.A., Arce, M.W., Jepson, Z.k., Bird, S.B., and Darling, C.E. (2015) Patient safety incident capture resulting from incident reports: a
comparative observational analysis. BMC Emergency Medicine. 15:6

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EMER - Consumer Reporting
 Launched in 2016
 Supported by ACEM and APSF
 First emergency medicine specific consumer reporting
portal in Australasia
 Analysed by expert data analysts and reviewed by people
directly involved in emergency medicine (ED directors and
physicians, ACEM, consumer advocates)
 Enables problems to be reviewed across all hospitals and
preventative strategies to be implemented accordingly

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Consumer Reporting – Why
report?
 Anonymous, online, secure reporting system
 Easy to use
 Only takes 5-10 minutes to enter an incident
 Information fed back directly to the specialty
 Protected under Qualified Privilege
 Incidents are reviewed from the consumers perspective!

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What can I report?
 Care that didn’t go as expected or planned
(e.g. Incorrect treatment/procedure performed etc)
 Care that went better than expected or planned
(e.g. Staff member going above the “call of duty”)
 Anything that nearly went wrong – “near miss”.
(e.g. nurse nearly administered the incorrect medication)

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Examples of reported incidents
Patient bought a live snake in a plastic
bag into ED
Miscommunication between treating
teams during patient inter-hospital
transfer

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What happens with my report?
0
10
20
30
40
50
Pre-ED…
During…
Entering…
Initial…
Further…
In-patient…
Departur…
Followin…
(blank)

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Incident submitted
Who did the experience
happen to?
Tell us what happened What was the result of your
experience?
How could your experience have been
prevented?
What could the emergency department
have done better?
Age Band Gender Country How recently did your
experience occur?
time of the
day
Your child My 5 year daughter was brought in to emergency with
an elbow fracture requiring surgery. We had to be sent
to a paediatric hospital and the doctors at the first ED
spoke to a consultant orthopaedic surgeon, who was
happy to take over her care/surgery at the paediatric
hospital. We arrived at the paediatric ED and told the
triage nurse, then the doctor and the nurse inside ED,
that we were expected by the consultant orthopaedic
surgeon. We waited and kept saying that the surgeon
was expecting us (as she needed a pin in the elbow).
She was in extreme pain. We did not seem to be able to
'get through' to any of the staff. After about 2 1/2
hours an orthopaedic registrar arrived and said "i don't
know anything about you'. We said "no we were
expected by the consultant orthopaedic surgeon about
3 hours ago. Registrar said "oh I'll go and let him know
you've arrived'. We just couldn't get any of the staff in
ED to listen to a very simple thing that we were saying.
We could have saved them a lot if time and effort if
they had listened to what we had to say. They all
seemed so distracted.
Just about a 3 hour delay,
frustration for us as parents and
pain for my child.
Simple listening and when a parent or
patient says something, assume it may
be true. I work in healthcare and was
amazed that I could not get my voice
heard.
When we arrived, I would have
appreciated if the triage nurse could
have just contacted the surgeon who
had accepted us and let him know we
had arrived. It seemed that everyone
was afraid to just believe us and contact
him. The communication practices in the
ED seemed very chaotic.
5 to 9 years Female Australia More than 12 months ago 2:00 to 2:59
pm

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Incident de-identified and
classified

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Data analysed
Count of
Burst
reporting
%
Diagnostic Error (eg missed/delayed fracture
diagnosis, dislocations, infections, myocardial
infarcts, cancer, stroke, embolism, appendicitis)
17 80.9
Airway Management (eg intubation,
laryngoscopy, equipment failure, human error,
system failure)
2 9.5
Medical Procedure (eg lumbar puncture,
sedation, fracture reduction, advanced line
insertion)
2 9.5
Grand Total 21 100

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Promotion and dissemination
of learnings
Deakin, A., Schultz, TJ., Hansen, K., & Crock, C. (2014). Diagnostic error: Missed
fractures in emergency medicine. Emergency Medicine Australasia : EMA.

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23. Where can I find “EMER”?
http://www.emer.org.au/

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EMER Contacts
Direct email
 emer@acem.org.au
 Anita.Deakin@unisa.edu.au
Via the website

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“Please see me”