A workgroup from the American College of Emergency Physicians Quality Improvement and Patient Safety Section queried the Pennsylvania Patient Safety Authority about emergency department (ED) procedural safety. Authority analysts examined ED events reported from July 2008 through June 2010.
Over the 2-year period, there were 55 reports of errors or complications associated with procedures conducted in the ED, other than wrong-site procedures, medication administration, or conventional intravenous access. The 55 reports of errors involved the following:
Eighteen pneumothoraces after central line insertions
One pneumothorax after rib blocks
One pneumothorax after endotracheal intubation
Two occurrences of subcutaneous emphysema after endotracheal intubations
Two oral injuries from endotracheal intubations
Two lung injuries from chest tube insertions
One abdominal organ injury from chest tube insertion
One unrecognized retained glove fragment after chest tube insertion
Seven hematomas from venipunctures
Six unrecognized arterial venipunctures, one of those central
Two hematomas from arterial sticks
Three retained guide wires
Two improperly secured central lines
Two occurrences of bleeding from Foley catheters
One bladder perforation with Foley catheter insertion
One perforation of the tympanic membrane with irrigation of the ear canal
One esophageal perforation dislodging a food impaction during endoscopy
One cerebral spinal fluid specimen discarded in the trash
One irretrievable needle fragment after a joint injection
The analysts applied the Authority’s surgical wrong-site procedure algorithm to the ED setting. Over the 2-year period, there were 46 reports of wrong-site procedures other than medication administration, laboratory tests, or intravenous access; 28 of which were actual wrong-site events and 18 were wrong-site near misses. The reports included the following:
- Nineteen of the actual wrong-site events were reports of wrong-site imaging; all the 18 near-miss reports were of wrong-site imaging, and most were caught as a result of patient input.
- Three involved wrong immobilizations; two involved immobilization of the wrong extremities and one involved the wrong type of immobilizer.
- Two involved chest tube placement on the wrong side, one with a resultant pneumothorax
- Two involved bladder catheterizations of the wrong patient.
- One involved injecting the wrong finger.
- One involved initiating a stroke protocol on the wrong patient.