EM · Medical error and patient safety

Medical error and patient safety in the emergency department

Also known as Open disclosure · Adverse event and near miss · Root cause analysis · Just culture · Incident reporting · Sentinel event · Never event

Medical error and patient safety in the emergency department — the systems approach via Reason's Swiss cheese model with the distinction between active failures (sharp end) and latent failures (blunt end), the differential of event categories (near miss, no-harm incident, adverse event, sentinel event, never event, negligence), the open disclosure protocol and the statutory duty of candour, incident reporting (what, when and how), the steps of root cause analysis, the common ED errors (diagnostic — missed MI, SAH and AAA; medication — dosing and allergy; procedural), just culture and the Marx algorithm distinguishing human error from reckless conduct, and the second victim. ACEM-primary, globally tagged.