The nature and causes of unintended events reported at ten emergency departments

Smits, Marleen; Groenewegen, Peter P; Timmermans, Danielle RM; van der Wal, Gerrit; Wagner, Cordula

doi:10.1186/1471-227x-9-16

Cited by 66Patient Safety and Medication ErrorsHospital Admissions and OutcomesEmergency and Acute Care Studies

The nature and causes of unintended events reported at ten emergency departments

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Smits, Marleen, Groenewegen, Peter P, Timmermans, Danielle RM, van der Wal, Gerrit, Wagner, Cordula·2009·BMC Emergency Medicine

DOI 10.1186/1471-227x-9-16PMC PMC2753307

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Abstract

BACKGROUND: Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs) are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure. METHODS: Study at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA) by an experienced researcher. RESULTS: 522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%), followed by organisational (25%) and technical causes (11%). Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital. CONCLUSION: Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.

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Emergency departments face problems with overcrowding, delays, cost containment, and patient safety.
“The need for improvement in emergency departments (EDs) with respect to the cost of care, the speed of service, overcrowding, and patient safety is now widely accepted [1–4].”
From Lean Thinking in Emergency Departments: A Critical Review (2011) · cites this paper as [4]

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Authors: Smits, M., Groenewegen, P. P., Timmermans, D. R., van der Wal, G., & Wagner, C.
Affiliations: Netherlands Institute for Health Services Research (NL)
Utrecht University (NL)
Corresponding author: Smits, Marleen
ORCID: Smits, Marleen
Groenewegen, Peter P
Wagner, Cordula
Venue: BMC Emergency Medicine
Publisher: Springer Science and Business Media LLC
Published: 2009-09-18
Volume: 9
Issue: 1
Pages: 16-16
ISSN: 1471-227X (ISSN-L)
DOI: 10.1186/1471-227x-9-16
PMC: PMC2753307
OpenAlex: W2023538669
Cited by: 66
References: 31
Citations by year: 2025: 4 · 2024: 2 · 2023: 3 · 2022: 3 · 2021: 4 · 2020: 4 · 2019: 2 · 2018: 4 · 2017: 6 · 2016: 7 · 2015: 12 · 2014: 6 · 2013: 2 · 2012: 1
FWCI: 3.16
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
creativecommons.org/licenses/by/2.0 (tdm)
Locations: BMC Emergency Medicine (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
Pure Amsterdam UMC (publishedVersion, other-oa)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by)
University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Topics: Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
Keywords: patient safety, emergency department, root cause analysis, event reporting, inter-agency cooperation, human factors, patient harm
MeSH terms: Documentation, Emergency Service, Hospital, Humans, Netherlands, Causality, Safety Management, Medical Errors

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The nature and causes of unintended events reported at ten emergency departments

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