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Safety in Accident and Emergency Care
1
Enhancing Safety in Accident and Emergency Care
Report of a series of studies funded by the National Patient Safety Research Programme
May 2006
Safety in Accident and Emergency Care
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Copyright Notice © Queen’s Printer and Controller of HMSO 2005
This report may be freely reproduced for the purposes of private research and study and extracts may be
included in professional journals provided that suitable acknowledgement is made and the reproduction is
not associated with any form of advertising. Applications for commercial reproduction should be
addressed to the Patient Safety Research Programme, The Department of Health, Richmond House, 79
Whitehall, London SW1A 2NL.
Enhancing Safety in Accident and Emergency Care
Maria Woloshynowych
Rachel Davis
Ruth Brown†
Robert Wears*
Charles Vincent
Melinda Lyons**
Competing interests declared: ‘none’
The Clinical Safety Research Unit Imperial College, University of London Department of Bio-Surgery & Surgical Technology
10th Floor QEQM, St Mary’s Hospital
Praed Street
London W2 1NY
England
Phone: 020 7886 2124
www.csru.org.uk
* Dept. of Emergency Medicine, University of Florida, Jacksonville, Florida, USA
† Accident and Emergency Department, St Mary’s Hospital, Praed Street, London W2 1NY ** Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, CB2 1PZ
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ACKNOWLEDGEMENTS
Patient Safety Research Programme
The Department of Health
Richmond House
79 Whitehall
London
SW1A 2NL
http://www.pcpoh.bham.ac.uk/publichealth/psrp/
The Nuffield Trust
59 New Cavendish Street
London
W1G 7LP
mail@nuffieldtrust.org.uk
Smith and Nephew Foundation
15 Adam Street,
London
WC2N 6LA
http://www.snfoundation.org.uk/
We are grateful to Dr Sally Adams, who has advised on human factors aspects of the studies in this
report; to Catherine Tighe for data collection and analysis on the incident reporting and contribution to the
communication studies; and to Dr Melinda Lyons for her contribution to the design, data collection and
analysis of the triage and the barrier analysis studies. We thank our medical, nursing, managerial and
administration colleagues for their time, support and co-operation in this research. In particular, we thank
Jo Fisher, Julia Gamston, and Martin Frowd in the Accident and Emergency department for their
contribution. We also thank Professor Sir Ara Darzi FRCS for supporting this research.
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LIST OF ABBREVIATIONS A&E Accident and Emergency Department
AHRQ Agency for Health Care Research and Quality
ANOVA Analysis of Variance
CDU Clinical Decisions Unit
CE Communication Event
COM Communication Observation Method
CRM Crew Resource Management
CSRU Clinical Safety Research Unit
DoH Department of Health, UK
ED Emergency Department
ENP Emergency Nurse Practitioner
GP General Practitioner
HRA Human Reliability Analysis
HTA Hierarchical task-analysis
ITU Intensive Care Unit or Intensive Therapy Unit
NHS National Health Service, UK
NIC Nurse in Charge
NPSA National Patient Safety Agency
SD Standard Deviation
SHO Senior House Officer
SN Staff Nurse
Sr Sister
UK United Kingdom
US United States
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EXECUTIVE SUMMARY
The Clinical Safety Research Unit was funded by the Patient Safety Research Programme in autumn of
2003 to carry out a Programme of work on ‘Enhancing the safety of emergency medicine’. This funding
helped to establish a unique centre of research in the UK dedicated to enhancing safety in healthcare.
The work was performed within a single Emergency department in a London teaching hospital during
2003-5. The purpose was to explore certain issues and solutions in this department that might be
transferable to other departments, recognising the variation in processes and case mix in Emergency
departments in this country. The complexity of the emergency care pathway and the wide clinical case
mix meant that we concentrated on looking at safety aspects of processes that aid clinical decision
making rather than the care of clinical entities themselves. The work was undertaken while the four hour
target for time in the department was being introduced and the study department was therefore
undergoing a period of enormous change. This had impact on some of the studies and interpretation of
data. The work carried out on this grant was exploratory and a considerable number of studies were
carried out on a range of topics:
A retrospective study evaluating the incident reporting process, described in Chapter 3, showed that there
were more near misses and minor events reported in the dataset than those judged to be serious or
moderate. The largest group of reported incidents reflected problems of delay in the accident and
emergency department which may reflect the emphasis on time in department during that period.
Analysis of the system did demonstrate inaccuracies and allowed the department to raise awareness of
the reporting requirement.
A retrospective case analysis is illustrated in Chapter 4 which provides a graphical representation as well
as a narrative summary of a patient with chest pain who received delayed treatment. This method may be
a useful additional tool in the analysis of incidents. Chapter 5 shows how conducting a prospective
barrier/safeguard analysis can generate creative solutions to problems. We have shown that barrier
analysis, a method of error reduction used in other industries, can be successfully adapted for healthcare
and produced useful results. An additional potential benefit is that staff may start to naturally consider
barriers in their work – which could have a positive effect on practice as well as safety culture.
Two ethnographic studies are described in chapters 6 and 7. A communication study shows that the
nurses in charge of the accident and emergency department had to deal with high levels of
communication as part of their daily working activities and the potentially serious implications for patient
safety. In chapter 7 we describe a study to evaluate the efficiency of the triage process. The mean time
that patients waited to be seen for triage was 13 minutes 33 seconds and the triage process on average
took 4 minutes and 19 seconds. Efficiency was not enhanced by seniority of staff but was dependent on
external factors or the requirement to conduct non clinical tasks.
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There are various clinical implications regarding these findings. We have evidence of the high level of
communication for the nurse in charge in a busy London A&E department as well as support for previous
studies regarding waiting and triage process times. Evaluation of the reporting system together with local
initiatives have resulted in various changes including the piloting of an electronic reporting system. It is
anticipated that this will improve the reporting rate and that subsequently we will have a better impression
of the types of incidents that occur in A&E, thereby enabling more effective interventions to reduce such
incidents and so improve patient safety.
In summary, providing health care in emergency settings is complex, hazardous work that is vulnerable to
failure. Human Factors and ergonomics studies of hazardous work in other settings have produced
useful insights, innovations, and have contributed to improving safety in those fields, so there is great
interest in applying similar methods to the study of clinical work. However, the clinical environment
presents some unique challenges to researchers. We discuss some of those challenges and offer
suggestions for future work in this area including a review of the recently introduced electronic reporting
system, assessing the effect of analysis tools of staff’s understanding of safety, develop additional
systems to redirect unnecessary communications for the nurse in charge and monitor the effect of
electronic handover at triage, using non clinical staff in different ways. Other areas of interest include
attitudes to the incident reporting process, staff perception of board rounds and unscheduled returns to
the accident and emergency department.
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Contents
Page number
Acknowledgements
3
List of abbreviations
4
Executive Summary
5
Chapter
1. Introduction
8
2. Safety Research in A&E: the nature of the problem
13
3. Incident reporting in A&E 17
4. Case analysis: Graphical Representation of Incidents in A&E 23
5. Using Barrier/Safeguard Analysis to help improve patient safety within the medication process
28
6. Communication patterns in Accident and Emergency 34
7. Evaluation of the Triage Process 44
8. Conclusion 49
References
53
Appendices
60
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1 Introduction 1.1 Background Several important new initiatives in the last few years underline the increasing attention paid to medical
error and patient safety. Studies in the United States, Australia and Britain suggest that 4-16% of
patients admitted to acute hospitals are harmed in some way by medical interventions1,1-3. The report of
the Institute of Medicine on ‘Building a Safer Healthcare System' starkly set out the scale of harm of
patients and an ambitious and radical agenda for change, which attracted Presidential backing in the
United States4. In Britain, the Department of Health commissioned a major report ‘An Organisation with
Memory', a report covering similar ground to the Institute of Medicine report, but in a British context5. This
was followed by ‘Building a safer NHS for patients' which describes the new national incident reporting
system and establishes the ‘National Patient Safety Agency' 6.
Human error is routinely blamed for disasters in the air, on the railways, in complex surgery and in
healthcare generally. However, quick judgements and routine assignment of blame obscure a more
complex truth. While a particular action or omission may be the immediate cause of an incident, closer
analysis usually reveals a series of events and departures from safe practice, each influenced by the
working environment and the wider organisational context. True high reliability organisations are
cognisant of the need to examine and attend to the whole system of work and its design and
management. Understanding the characteristics of a safe and high performance unit or hospital therefore
requires research on a number of interrelated topics. Some of the most important of these, in the context
of Accident and Emergency (A&E), are the development and maintenance of individual skills, the crucial
role of both formal and informal communication, the impact of working conditions on team performance
and the need to understand the particular environment of A&E. In addition the culture of a unit or an
organisation is likely to be highly influential7.
1.2 The Accident and Emergency Environment The emergency department is a complex and difficult environment in which to provide medical care and
differs substantially from more traditional settings in the organizational and cognitive burdens placed on
caregivers. A&E typically consists of the following physical areas: reception where patients register for
treatment, triage room for their initial assessment by a trained nurse and, depending on the urgency or
their condition, their allocation to physically separate areas of the Department. These are called ‘minors’,
‘majors’ or resus (resuscitation) and “paeds” if there is a dedicated paediatric department. The Minors
area is for less serious injuries such as sprains, cuts and bruises, and these patients are referred to as
the "walking wounded". The Majors area is for seriously ill or injured patients who tend to arrive by
ambulance. Some departments also have a Clinical Decisions Unit (CDU) for patients who require a
longer period of observation before discharge or await a time critical diagnostic test before treatment can
be given. The recent introduction of the 4 hour targets are a considerable influence on the work in A&E8.
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These targets specify that A&E care should be completed within four hours from time of arrival at hospital
to the time that the patient is admitted, transferred or discharged. In addition, there are several aspects
of emergency care that make it qualitatively different from care rendered in more traditional settings, and
likely make it more vulnerable to error. Wears and Sutcliffe 9 have identified six factors that characterize
the emergency environment and which together make it unique in healthcare settings:
Unboundedness. Unlike other care areas the demand for emergency care has no upper limit. It has
been remarked that, “ A&E is the only infinitely expansible part of the hospital,” alluding to the common
practice of holding their patients in A&E to deal with blocked beds elsewhere.
Multiplicity. Emergency caregivers typically treat many patients simultaneously; while this occurs in other
settings, it occurs to a much greater extent in A&E. Multiplicity creates a potential for cognitive overload,
in that workers can only attend to a finite number of tasks simultaneously, and the tremendous variability
of clinical problems encountered. Emergency caregivers must simultaneously manage children and
adults, surgical and medical complaints, life-threatening and trivial conditions
Uncertainty. A&E clinicians operate with much greater levels of uncertainty than other clinicians. First,
there is in no limit to the range of problems that may be encountered. In contrast a cardiologist, for
instance, can in general count on his or her next patient to have a heart problem, however unspecified.
Second, information that is known and present somewhere in the system is frequently unknown or
unavailable to emergency caregivers at the time of the patient encounter. Current and past medications,
allergies, results of past diagnostic evaluations are frequently unobtainable.
Time constraints. While production pressures are certainly present in other care areas, the time
constraints of A&E care are severe (clinicians in some departments typically average between 4 to 6
patient dispositions per hour during peak times). This can cause a narrowing of focus and a rush to
judgment, creating both false positive and false negative errors in a form of speed - accuracy tradeoff. In
addition, in some true emergencies (e.g., upper airway obstruction) the window of opportunity for
successful action is brief and physicians must rapidly commit to a course of action without waiting for
greater certainty if they are to have any chance at success.
Lack of feedback. Emergency caregivers routinely receive little to no feedback on the results of their care.
Systems for returning outcome information to A&E practitioners are uncommon to nonexistent. It would
seem almost impossible for learning from experience to occur under such conditions.
Reduced opportunity to practise. In many other domains, expert practitioners routinely perform their most
dangerous tasks frequently. For example, pilots take off and land several times a day, anesthesiologists
induce, intubate, and recover frequently, and surgeons operate daily, but in A&E the riskiest procedures
(e.g., emergency intubation, cricothyrotomy, thrombolysis) are among the least commonly performed,
sometimes on the order of monthly, yearly, or even less often. This makes it easy for practitioners in
emergency settings to become mis-calibrated about their own capabilities. Such a wide variety of
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presenting complaints result in even the straightforward diagnoses being seen only rarely in one
individual’s term of employment, particularly if only employed for 4 months in a particular department.
These six factors are not the only ones that affect performance in A&E; for example, shift work, sleep
loss, and heavy dependence on services outside the A&E (laboratory, radiology, consulting services, etc.)
also play a role10. A crucial factor in the British context is the junior level of most staff and the lack of
suitable training and skills brought to major emergencies11. In addition, the use of other independent
practitioners in A&E is increasing. Emergency Nurse Practitioners are able to function autonomously
after a short training period (6 weeks); these and other physician extenders (e.g., paramedics) can
discharge “minor” cases without review by senior colleagues according to local protocols. This lack of
senior review exposes the department to risk on a daily basis. This is compounded by a rapid turnover
among nurses, particularly in some busy inner city hospitals. Furthermore, in the UK where emergency
medicine is a relatively new specialty, only about 30% of patients are reviewed by a physician with more
than 18-24 months experience, and that review is initiated by the junior physician, rather than being
performed systematically. The recent introduction of European directives on doctors’ working hours may
have reduced the effect of fatigue on performance but the effect of this on staffing levels along with recent
changes in medical school training in the UK and lack of supervision are likely to have other knock-on
effects on patient care.
1.3 Studies of Adverse Events and Care Processes in A&E
There have been few focused investigations of errors, incidents and adverse events in A&E, and even
fewer into their nature and contributory factors. What is available in the literature offers glimpses of the
problem but does not provide a great deal of understanding into the origin, nature, causes or prevention
of errors and incidents.
Major epidemiological investigations have consistently identified significant rates of preventable error
occurring in all stages during episodes of care within emergency departments1,2,12,13. These studies all
suggest that while emergency care accounts for only a few percent of the total adverse events in
hospitalized patients, roughly three quarters of them were judged highly preventable, a proportion much
higher than any other area of care. Because these studies were based on record reviews, and only
included review of the care of patients who were admitted (while roughly 80% of A&E patients are not
admitted to inpatient units), it is likely that the burden on preventable injury is even higher.
More direct studies of emergency care have borne out these results, both globally14,15 and in specific
problem areas such as chest pain and cardiac disease16 patient complaints and negligence cases17-20.
Studies of work processes in the A&E have shown that interruptions are frequent21,22, averaging roughly
once every 6 minutes, and that most interruptions led to a change in task. Similarly, observational
(ethnographic) studies have shown that direct communication among caregivers is particularly important,
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although almost a third of the communications were interruptions23-25, suggesting that the combination of
interruptions and multiple concurrent tasks may contribute to failures.
1.4 Human factors approaches in medicine Human factors is a discipline that spans engineering, cognitive psychology and ergonomics and emerged
specifically in response to the safety concerns of high risk industries. While theoretically based it has a
resolutely practical emphasis, always aiming to bridge the gap between theory and application26. The
human factors community outside healthcare has developed a variety of approaches and techniques to
assist in error identification, containment and prevention. Initially, the focus was retrospective in that past
incidents and accidents were investigated and analysed in order to develop error reduction strategies to
prevent future failure. However, the focus has only recently moved towards direct observation of work27
and anticipation of problems, using such techniques as probabilistic safety assessments, which assess all
types of human, hardware, environmental and software failures.
Within medicine Reason’s organisational accident model has been an influential general framework,
which integrated much of the available human error theory and human factors knowledge28,29. This
model illustrates how the conditions in which people work influence their performance. These working
conditions relate to a whole range of factors including management decisions and organisational
processes. Reason’s work has been a powerful influence in shifting the safety culture of healthcare from
one of blame and retribution to a learning organisation. The Reason Model has been adapted specifically
for use in healthcare and a protocol for the investigation and analysis of clinical incidents has been
developed and tested in a number of clinical settings30-32. This adapted model is described in chapter 4.
Vincent and Taylor-Adams have developed the protocol for investigating and analysing adverse incidents
in healthcare, to include other root cause analysis techniques33. They have also developed the theory of
human error by dissecting its essential ingredients to help understand the underlying cognitive failure
mechanisms, which will subsequently improve error reduction. Human factors is now being incorporated
into healthcare by other researchers. For instance, Joice et al. have utilised Human Reliability Analysis
(HRA) within endoscopic procedures34. Mistakes and their precursors have been investigated in high
hazard cardiac surgery35 and pharmacy36.
The work carried out on this grant was exploratory and a considerable number of studies were carried out
on a range of topics. The work was performed within a single Emergency department in a London
teaching hospital during 2003-5. The purpose was to explore certain issues and solutions in this
department that might be transferable to other departments, recognising the variation in processes and
case mix in Emergency departments in this country. The complexity of the emergency care pathway and
the wide clinical case mix meant that we concentrated on looking at safety aspects of processes that aid
clinical decision making rather than the care of clinical entities themselves. The work was undertaken
while the four hour target for time in the department was being introduced and the study department was
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therefore undergoing a period of enormous change. This had impact on some of the studies and
interpretation of data.
The full details of these studies are in the process of being published in a series of papers. In this report
we aim to provide a succinct overview of the whole programme of work. Therefore, this report includes
illustrative findings for each study to show the breadth of the work carried out. It is structured in the
following way: the next chapter explores the difficulties in conducting patient safety research in healthcare
with particular attention to the A&E setting, including ethical approval which was obtained from the
institutional ethics committee. This is followed by work which looked at the incident reporting process in
A&E. This process is described and evaluated in Chapter 3, with a illustrative case to show a detailed
analysis of an incident in Chapter 4. A prospective method of error reduction was applied to the
medication process in Chapter 5 and Chapter 6 describes a study on communication load for the nurse in
charge of A&E. Chapter 7 gives an account of time spent on the various tasks in triage. The final chapter
discusses the implications of these studies and suggestions for further work.
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2 Safety Research in A&E: the nature of the problem 2. 1 Introduction
Accident and Emergency is a field of practice where risk is high and failure a constant threat. Therefore it
would seem a natural laboratory for researchers interested in understanding and improving human
performance under demanding conditions. However, our experience in both the US and the UK has
demonstrated multiple barriers to effective research efforts.
The analysis reported here is based on the direct experience from various current and previous research
projects, involving teamwork among clinical professionals37, ethnographic analyses of emergency
care38,39, organisational factors in patient safety40, shift change reports and transitions in care in the
A&E41-44, reporting of incidents and adverse events45, use of artefacts to support shared cognition46, and
the effects of technology on clinical work safety47,48. In this chapter we use a fundamental ergonomic
question (“What makes this work hard?”) reflexively, to ask: “What makes studying this work hard?”
In these studies, we have encountered a number of expected and unexpected difficulties. Some of these
barriers are generic, applying to many areas of healthcare, while others seem specific to studies in A&E.
2.2 What Makes Studying Clinical Work Difficult?
Problems generic to all healthcare settings Many of the problems we have encountered in studying safety in A&E have also been encountered in
other areas of healthcare. We briefly review six of the more common ones here and suspect that, except
for the last category, they will all be somewhat familiar to field researchers.
First, developing the sustained and substantive collaboration needed for productive work can be difficult.
Clinicians are generally unfamiliar with the methods of the “safety sciences”, and by nature and training
tend to assume that they will take the lead in solving problems. They need the insights, tools, theories
and particularly, the knowledge of the “blind alleys” that human factors professionals bring, but are often
unaware of their need. Human factors researchers, in turn, need help in acquiring access to clinical
areas and healthcare professionals, and in understanding and clarifying the semantics of the domain49,50
and the particular norms and culture of each clinical area in each institution.
Second, the complexity of healthcare is daunting. The scale of healthcare activity is immense, the
number of different activities is enormous, and the number of potential interactions between actors and
processes seems nearly unimaginable. The truth is “in the details”, but knowing (in advance) which
details are important and worthy of attention is difficult. Researchers have tended to react to this
complexity by “bounding it out”, doing small focused studies on parts of processes, but Nemeth and Cook
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have argued that such a strategy is not appropriate for a problem space about which little is
understood49,50.
Third, developing the requisite trust of the subjects to be studied can be difficult. Health care
professionals are extremely busy, and so have little time to get to know researchers, especially if the
interactions only occur on a sporadic or occasional basis. Most will begin with an underlying suspicion
that the researchers will either not understand the issues they face, or will sensationalize their problems,
or both. They are also likely to interpret safety research as being a search for errors and culprits, due to
the pervasive culture of personal responsibility and blame that health professionals share8. Because of
this, they will wear a variety of masks when dealing with outsiders that may be difficult to penetrate50.
Fourth, healthcare organizations are organizations only in a very loose sense of the word. Clinical
workers belong to multiple overlapping and intersecting groups which live together in tense social webs49.
Researchers who fail to recognize this larger context may find themselves unwittingly co-opted into intra-
organizational struggles that can impede their effectiveness.
Fifth, is the problem of facility, an issue that human factors professionals are familiar with. The great
expertise that clinicians have in their field of work ensures that the difficulties they face and the
adaptations they make to overcome them disappear, to both observer and observed49.
Finally, studies in health care bring pragmatic and regulatory issues that are uncommon in other areas
ergonomists have studied. In contrast to human factors studies in industry or the military, virtually all
human research conducted in health care is subject to regulatory and ethical review before beginning the
research project, and to continued oversight during its execution. These problems are further
compounded by the fact that the local ethics boards are generally only familiar with biomedical research,
and thus have a great deal of difficulty in assessing ethnographic, observational or qualitative research
designs, and can be expected to struggle with issues of scientific validity, identifying who the subjects
are, and whether consent is needed, and from whom.
Problems Specific to A&E In addition to the generic difficulties common to safety research in all areas of health care, we have seen
a number of problems that, if not unique to the A&E setting, seem more commonly encountered there. At
least 5 major issues are prominent in this area.
The first issue is one of multiplicity. Most safety research in health care to date has concentrated on
single tasks, such as the course of an operation or an anaesthetic. We realize there are in fact many
complex tasks in these, but they are for the most part subsumed into the larger task; thus the issue is one
of understanding many logically unrelated but interacting tasks. Clinical work in emergency care is
characterized most strongly by the management of multiple different tasks in parallel – “managing the
stack”. This raises several problems for researchers. With many tasks and activities underway, it is
difficult to know which ones to attend to or even how to make such a decision. In addition, there do not
seem to be good tools for representing this dimension of the complexity of emergency work. The
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narratives about failures or near misses, although rich and complex, inevitably seem to boil down to
single task stories, involving a small set of actors dealing only with a single problem: as it were, one
doctor, one nurse, and one patient. The reality of clinical work is far from this sense-making
simplification, but we have not yet developed tools that allow us to capture and express the multiplicity of
the work. This tends to make judgments retrospective and dependent on knowledge of the outcome, with
all the difficulties that entails51-53.
The second issue is the distributed nature of A&E clinical work. Work is distributed over patients, over
space, and over providers. The distribution over patients is expressed in the multiplicity issue discussed
previously, but the distribution over space and providers creates practical impediments to research that
uses observation methods. In sharp contrast to the cockpit, or the operating theatre, where the activity
that is the subject of the observations is physically restricted to a relatively small area, A&E work goes on
simultaneously in multiple, physically removed locations. This makes it hard to keep track of all that is
going on, and difficult to use recording devices as aids to observation except for limited purposes.
Furthermore, if observers choose to follow providers (or patients), then the observations will be as
fragmented as the work is. The distribution of the workload between workers is equally problematic, since
workers will be physically distributed and their tasks will be logically and temporally distributed.
The third issue relates to documentation. Since direct observation of A&E care presents difficulties, an
alternate strategy might be to examine the traces of work that are left in the artefacts clinical workers
use54. Unfortunately, there are still difficulties here in A&E care. Some of the important artefacts, such as
the status board, are evanescent, with information being added or removed as patients enter or leave the
A&E. Thus artefacts such as the status board are memory-less; they give snapshots of current work, but
no traces of previous work. Documentation or record keeping in emergency care is traditionally scanty,
for several reasons: time pressure limits the amount that providers are willing to record. A small study to
see if review of the A&E chart could successfully detect incidents that had been previously reported in an
anonymous reporting system showed that the majority of such incidents were undetectable55. Both the
UK and the US have problems in settings when some records are maintained on computer and others on
paper.
Other potential traces documenting A&E clinical work have been similarly problematic. Diagnostic coding
is often assigned at the end of a hospital admission, and so reflects many other processes than A&E
care, and there is no standardized coding for presenting complaints. Studies of clinicians dealing with
problematic cases (such as chest pain suggestive of cardiac ischemia, or headache suggestive of an
intracranial haemorrhage), have been hindered by the tendency of receptionists to use broad general
categories (such as “unwell adult”) when registering such patients.
The fourth major issue is the natural time scale on which events unfold. Things tend to happen rapidly in
A&E, so rapidly that it may be difficult for observers or practitioners to grasp them, and especially to grasp
the features of the context that are pertinent to understanding how things went wrong or how practitioners
were (un)able to recover.
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The fifth difficulty is in discovering outcomes. In inpatient settings, the patient’s course is generally
observable or retrievable, but this is not the case for outpatients, who may go elsewhere for their
subsequent care. Since approximately 80% A&E patients are discharged directly from A&E, the potential
loss to follow-up is great. And, although those discharged are, on average, less ill (or injured) than those
admitted to hospital, some of the most consequential failures in A&E care stem from discharging a patient
who should have been admitted (for example, with unrecognized myocardial ischemia). These are often
the cases safety researchers are most interested in, but are difficult to identify, and even more difficult to
retrieve and analyze if the patient’s pathway crosses institutional boundaries.
2.3 Implications for the research programme The characteristics of emergency work highlighted in this chapter make both the study and practice of
safety particularly challenging. There were numerous occasions where observations or data collection
had to be abandoned or postponed due to the high work load, or unpredictable and urgent nature of the
A&E environment. Initially we had difficulties being accepted by the A&E staff, making it difficult for
research staff to familiarise themselves in this busy and unpredictable environment. Part of the difficulty
was that some staff misunderstood our purpose, thinking that we were there to observe any mistakes
they might make. Furthermore, changes to systems used by staff (such as the introduction of a new
patient information computing system) and national changes (i.e. the introduction of four hour targets)
have a knock on effect on our research aims, objectives and subsequent achievements. Clinical staff
have had to adapt to these changes which has been and we’ve had to postpone data collection or even
change the focus of the research.
Our work in A&E was necessarily exploratory and a prelude to more focused studies on the key issues of
decision making and communication in the future. Our aim was to explore different areas to identify
possible lines of enquiry. A preliminary safety culture survey was conducted to demonstrate the research
process to staff in particular timely feedback to reassure staff that we were not there to observe for errors.
This proved very valuable and enabled us to build a good working relationship with the A&E staff. We
have explored the range of areas in the proposal but have focussed on the projects that make up the next
five chapters. These projects were chosen as they give an insight into the different aspects of the unique
A&E environment and provide a broad basis on which to conduct future research. We have used a range
of different methods of research. In addition, these studies reflect the interests and areas of concern of
our clinical colleagues.
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3 Incident reporting in A&E 3.1 Introduction
The development of clinical risk management in the United Kingdom and elsewhere led to the
establishment of local incident reporting systems in hospitals. There may be a designated list of incidents
that might prompt a report, a “trigger list”, although staff are free to report other issues that do not fall into
these categories. Generally the incident is classified as to the type of incident i.e. drug error, lack of
records, missed diagnosis, as well as allocating contributory factors.
When an error or clinical incident occurs it needs to be reported so that lessons can be learnt from the
incident. In addition, reporting reduces the possibility of reoccurrence and enables monitoring of patient
safety issues particular to the department involved and the trust as a whole. The incident reporting and
reviewing process within the study A&E department is reported elsewhere45. Despite efforts to
encourage reporting and the establishment of a national reporting system at the National Patient Safety
Agency (NPSA), there are still a number of barriers to reporting such as fear of reprisals, loss of
reputation, extra work or poor understanding of the process of investigation of an incident56. Furthermore,
there are mixed responses to the investigations of errors, some of which have the potential for learning
and improving care57.
The overall aim of the study was to evaluate the use and effectiveness of the reporting system as used in
the A&E department. The objective of the study was to assess the process of reporting and reviewing
incidents within the department, using historical data to explore the usefulness of the data recorded. We
also wished to make recommendations to the department for revision of internal processes so that the
department maximises the accuracy of data reported centrally and can learn from it.
The reporting process The staff member who becomes aware of the incident, fills in the incident report form and discusses the
reported incident with the nurse in charge of the shift or most senior doctor present. The person reporting
the incident at the time classifies the incident according to the categories supplied with the incident report
book. They provide the information on those involved and a factual description of what happened,
including any injury and treatment given.
The form is then reviewed by one of the members of the A&E clinical risk management committee (senior
clinicians), who makes an initial assessment of the potential impact of the incident including the
consequence of the incident in terms of severity and the likelihood of recurrence (ranging from ‘rare’ to
‘almost certain’). These two judgements combine to give a risk evaluation score. Comments on
preventive measures taken or planned (such as an investigation) are also included. They also note any
obvious contributory factors at that time.
Safety in Accident and Emergency Care
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At this stage a copy of the form is sent to the Trust clinical risk management office. This naturally occurs
before the full investigation is completed, and the department aims to get the forms to the central risk
management team for recording on the electronic system within 1 working day of the incident. The
evaluation of the severity, contributory factors and action points is therefore an estimate at this time
pending the result of the investigation. Serious untoward clinical incidents (unexpected death or serious
outcome) are escalated within 24 hours to the trust Executive director for Clinical Governance and
investigated via a different mechanism.
Once a month a short report listing all recent incidents, including serious untoward incidents, is sent to
the A&E clinical risk management committee. This summary report is then discussed at the next A&E risk
management meeting (usually at least a month after the incidents occurred). Each incident is discussed
and the relevant senior member of the committee gives an update on results of their investigation and
further action points. Information is not routinely updated onto the system from these minutes as there is
no clear line of responsibility for this action.
3.2 A review of the incident reporting system
Method We reviewed 13 consecutive months of data from the A&E section of the Trust electronic database of
clinical incidents. The data reviewed included the 174 incidents reported during the period from March
2003 to March 2004. The researchers used the free text information stored as the incident description on
the database, and compared this with the category and the severity score recorded on the database. The
contributory factors recorded and relevance to the clinical incident described were also noted. The
descriptions of incidents are short, and so this required some interpretation. Therefore only major
discrepancies between the event that was described in the incident notes and the category type allocated
were noted.
Results 1. Description of the incidents reported.
a) Types of incidents – completed by staff reporting incident
Figure 3.1 shows the types of incidents reported using the trust categories and an additional one for delay
to patient care as this type of incident is featured in more than one grouping. The largest category,
delays, were due to various causes; lack of porters or difficulty in arranging for patients to be seen
promptly by specialty doctors were the main features. Staff also reported instances when patients were
not discharged from A&E within the national 4 hour targets. 38 incidents in the ‘General’ grouping
included 5 cases of ‘sub-optimal care’ (where staff reporting the incident judged that the patient did not
receive adequate or appropriate care in the department) and 15 ‘drug’-related incidents. Of the 34
‘Patient Care’ grouping, 8 cases related to ‘lack of facilities or equipment’ and there were 5 incidents
where patients ‘did not wait’. The ‘other’ category includes a variety of incidents that were judged by the
staff not to fit the themes already mentioned.
Safety in Accident and Emergency Care
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b) Severity of incidents – reported by staff reviewing and investigating incident
The incidents ranged in severity: 95 Near Misses, 37 Minor, 16 Moderate and 20 Serious incidents. Six
incidents were not categorised in terms of severity. Incidents classed as ‘Near Misses’ had the potential
to cause harm to the patient but did not actually result in any harm. It is encouraging that staff regularly
reported Near Miss incidents as safety can be improved from learning from these incidents as well as
incidents which result in actual harm. The number of ‘Serious’ incidents reported was considerably lower
than incidents classified as minor or near misses. Examples of serious, moderate and minor incidents are
shown in Box 3.1.
Figure 3.1: Types of incidents
* delay is featured in more than one grouping and has been given a separate category in this report.
BOX 3.1: Examples of Severity ratings for incidents Near Miss
Very unwell patient was transferred by ambulance with no handover from a different hospital except
'deterioration'. There was no prior warning to A&E department.
Minor
SHO asked for bloods to be collected from majors. The porter was bleeped, there was no reply and the
doctor was informed that there were only two porters in hospital, and no A&E porter.
Moderate
A clinically unstable patient was transferred to a ward.
Serious
A patient with acute chest pain was triaged as category 3. There was a delay of 14 minutes for ECG. ECG
showed that the patient had suffered an acute MI.
010203040506070
delay*
Genera
lDiag
nostics
Patien
t car
eStaf
fing
Proced
ural
Non cl
inical
Other
Safety in Accident and Emergency Care
20
c) Contributory factors completed by staff investigating
Contributory factors were mentioned in 22 of the 174 reported incidents (see Table 3.1). The most
common factors identified were ‘Communication problem’ and ‘staff shortages/skill mix’. 152 incidents
had no contributory factor identified on the database.
Table 3.1: Identification of contributory factors
Contributory factor Frequency
Communication problem 6
Staff shortages /skill mix 6
Failure of checking procedure 3
Missing or delayed: Results/ X-rays / Patient 2
Delay /difficulty in obtaining assistance 1
High work load 1
Deviation from policy/ guideline/ ICP 1
Lack of equipment 1
Failure of cover/ Handover/ Bleep system 1
d) Positive action from incident reporting
The Risk Management team in the department routinely identified positive action to be taken from the
incident reports. For example, there was a long delay in getting the blood products and appropriate
reversal for a warfarinised patient with haematemesis. This prompted a trust wide protocol for dealing
with warfarinised patients with Gastrointestinal bleeding with recommendations for reversal of
warfarinisation as well as re-education on the massive blood transfusion protocol for staff. In addition,
new guidance for calling a consultant in from home was agreed between consultants and this was
circulated to staff.
Other new positive aspects introduced since the study of the incident reporting and review system in the
A&E department is the quarterly newsletters which highlighted learning points from incidents. These
newsletters acted as reminders to all staff of good practice for aspects of their work which was related to
the incidents reported as well as reminders of new policies that have developed out of the clinical incident
reporting.
2. Evaluation of Information on the database.
In examining the incidents in the database the researchers identified apparent weaknesses with the local
internal processes in reporting incidents and limitations with the information recorded on the database.
Safety in Accident and Emergency Care
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Examples of issues identified include: Inconsistent use of categories. Some incidents were classified
under different names from the trust classification list on different occasions, e.g. missing patient (left with
venflon in situ) / sub-optimal care (left with venflon in situ); and Incomplete reports, missing information,
e.g. missing information on incident/ classification/ contributory factors, etc.
The lack of detailed information on the type of incident or contributory factors means that important
information which could lead to patient safety improvements was sometimes missing, thus not giving
enough detail to be able to monitor trends and issues. If clinical incident reporting is to be an alarm
system to prevent serious incidents or adverse events from re-occurring5 it is very important that we are
able to recognise real patient safety issues. For example, if we are unaware of the frequency with which
we are unable to find an ITU bed for a patient in a particular district or area, we will not recognise when
such an issue needs to be brought to the attention of NHS managers.
3.3 Discussion Incident information on the database was comprehensive enough to allow descriptions of the type and
severity of incidents to be summarised. We know that not all incidents which occur are reported58. There
are various reasons for this56 which might explain why there are more near misses and minor events in
this dataset than those judged to be serious or moderate.
Studies have also shown that even with explicit criteria and definitions, inter-rater reliability can still be
relatively low; for example, when judgements are made on the presence of an adverse event when
reviewing patients’ records59. Despite these limitations in human judgments and actions we have
suggested changes to the following aspects of the incident reporting system: Updating the database
The information on the database was not complete in that for some cases a full investigation had been
carried out but that this was not updated on the database, and so the loop was not closed. To remedy this
we recommend use of an electronic reporting system where staff investigating the incidents are also able
to include additional information as it becomes available and hold the information locally until we have
complete information before sending it on to the central trust database. This will ensure that the trust is
informed of the outcome of the case as well as the staff locally. Classification of incidents
Classification of incidents is carried out by junior staff who do not necessarily appreciate the process or
the definition of the categories. We recommend providing training for all staff so that they appreciate the
full incident reporting process and the importance of completing the forms as fully as possible; that only
senior staff fill in this section or at least confirm the classification at the monthly A&E risk management
committee meetings.
Safety in Accident and Emergency Care
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The effectiveness of the intra departmental reporting system is somewhat difficult to assess, particularly
as the system in the study department was undergoing development during the study period. For minor
incidents the outcome of the incident or process was not always fed back to the person(s) concerned.
Sometimes information was given to the wider clinical staff, such as reminders about changes in
protocols. The staff do not receive a structured summary of the nature of incidents reported on a regular
basis, although they receive a copy of the newsletter highlighting learning points and new policies
introduced, and a regular structured summary of incidents for staff is being planned. Recommendations
therefore include individual feedback to the staff reporting the incident in addition ot the planned regular
structure summaries as well as those mentioned above. This all contributes to the learning loop which
reflects the cyclical process of reporting or monitoring, investigation, analysis, feedback, implementation
of changes and back to monitoring and subsequently could be extended to the wider organisation5.
Safety in Accident and Emergency Care
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4 Case analysis: Graphical Representation of Incidents in A&E 4.1 Introduction
Investigation of accidents and incidents (near misses) in healthcare is now commonly required. However,
the methods and techniques to support such analyses for learning are in their infancy. In practice, their
use often suffers from hindsight bias and a narrow search for the “root cause”60,61. The term root cause
analysis is sometimes mistakenly thought of as having one root cause33. This has been referred to as
“first story” analysis. In contrast, “second story” analysis identifies deeper vulnerabilities; problems that
often remain in systems of care even after “fixes” have been implemented for problems identified by “first
story” analysis47. We have adapted an analytic model used in high hazard industries (and tested in
obstetrics) to the emergency setting and have modified engineering methods for graphically representing
an incident in an A&E setting. These methods appear to more clearly identify fundamental vulnerabilities
that are persistent in the particular organization, which need to be addressed for healthcare to make
fundamental advances in patient safety.
The aim of this study was to use a case analysis to illustrate how graphical representation, in addition to
enhanced systems analysis33, can show how “second story” analysis reveals the underlying
vulnerabilities.
4.2 Methods
We used Vincent et al.’s33,62, analytic framework to structure the results. These levels of contributing
factors are: patient, provider, task (and tools), team, work environment, organisation, and the societal-
legal-regulatory milieu. We used an investigative approach developed by Dekker61 to gather the data and
formulate a sophisticated understanding of the factors behind these incidents. Finally, we adapted 2
graphical methods of representing accident scenarios (Multi-Event Sequencing63 and Event & Causal
Factors notation64) to express our understanding of how these events came to pass in graphical form.
The Case A chest pain patient presented for treatment, but was inadvertently misclassified at registration and so not
identified in the triage nurses’ work queue. The usual receptionist (registration clerk) was out and a clerk
from another area had been substituted. Several triage nurses were working at the time, and several
handovers occurred among the triage nurses, but none identified the patient as awaiting triage. A family
member asked about the lack of progress after roughly 75 minutes of waiting. The patient was promptly
triaged to the acute area and was admitted to the hospital for cardiac ischemia.
Safety in Accident and Emergency Care
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4.3 Results
Table 4.1 shows the various aspects of Vincent et al.’s 33,62, analytic framework, including the care
delivery problems, contributory factors, positive aspects of the case and recommendations.
Table 4.1: Cases analysis using Vincent et al.’s framework
Care Delivery Problems
1. Incorrect coding for the location for the patient – i.e. should have been on the screen that the
patient was waiting for triage.
2. Nurse in triage was not informed of patient with chest pain by receptionist.
3. The ‘extra’ patient (or patient not accounted for) was not identified during handover.
Contributory Factors
Clinical Context and
Patient Factors
• no patient factors (but it was fortunate that daughter asked about him being
seen)
Individual Factors
• Receptionist’s training regarding codings earlier in the evening and assumption
that didn’t need to tell nurse in triage
Task Factors
• There was inadequate time for the receptionist to inform the triage nurse of this
patient
• Nature of the task is such that it is easy to enter the wrong code
• There is no systematic way of ensuring that all patients in the waiting room are
accounted for as there is no way of easily distinguishing between patients
and relatives
Team Factors
• Receptionist should have informed the nurse of patient
• Patient or relative should have been told that he (or his condition) is a priority
and that he would be called next
• The patient’s daughter waited 1¼ hours before asking about the patient.
• The computer failed to display that there is a patient with chest pain waiting to
be seen for triage (this is part of the program)
• Handover error – Sr H did not know about the patient
• SN R was not given a handover.
Work/Environmental
Factors
• There was a sudden increase in workload: 7 patients arrived at the same time.
• There is nothing to prevent the mistake of entering the wrong code nor is there
any way of checking for such a mistake
Safety in Accident and Emergency Care
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Table 4.1: Cases analysis using Vincent et al.’s framework
Organisational and
Management
Factors
• Choice of computer system for patient information
• Emphasis of handover for busy times
• Currently there is no system to pick up missed patients
• Selection of staff and training for receptionists.
Positive Points
• The receptionist realised she made a mistake as soon as it was pointed out to her
• Nurse acted quickly once she realised there was a problem.
• An additional nurse was allocated to triage to cope with the high workload
• There is already a system in place to recover from incorrect coding of patients’ main complaint – that of
informing the triage nurse of a patient with chest pain – as was demonstrated earlier that evening.
Recommendations
• Once we know the reason for the incorrect code for location – then we may be able to suggest possible
ways of preventing it. There is already a back up system for entering the wrong code – that of
informing the triage nurse of patients with chest pain.
• Introduce a system for checking code input, especially during busy periods – i.e. when for example
more than 5 patients arrive at the same time and when nurses have their handover.
• Need a process of accounting for all persons in the waiting area, particularly at times of shift change or
handover.
• Involve patients in this procedure, inform them and their relatives that they will be seen next for triage.
In Figures 4.1 and 4.2 time proceeds from left to right; events are shown as rectangles and contributory
factors as ovals. Events or contributory factors supported by evidence are shown in solid lines; those
supported only by presumptive evidence are shown in dashed lines. Arrows show dependency and
precedence, not necessarily causation.
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Figure 4.1: Prelude to incident.
Chest pain pt presents to registration
Longstanding practice of registration before triage
Usual registration clerk out
Substituted by clerk inexperienced in emergency
procedures
Wrong code entered
Pt does not appear on triage nurse’s
screen
Clerk tells nurse about chest pain
patient
Nurse, clerk discuss
discrepancy
Clerk now believes unnecessary to tell
nurse if code is entered correctly
Figure 4.2: The incident
Another chest pain pt presents to registration
Wrong code entered
Pt does not appear on triage nurse’s
screen
Clerk does not tell nurse about chest
pain patient
?Pick-list problem
From Fig 4 - 1
Sudden influx of 7 patients
No method to determine if all pts
in waiting room have been triaged
Multiple handovers among
triage nurses
Pt not told he will be prioritized
Pt waits patiently for 75 minutes w/ continued chest
pain
Family member present, questions
long wait
Rapid assessment, admission to cardiology
Safety in Accident and Emergency Care
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4.4 Discussion
The “first story” of this incident is deceptively simple – the receptionist made a “mistake”. The “second
story” is richer and identifies more potentially correctable vulnerabilities. This incident occurred during a
busy time and at a time when staff were changing shifts. If there had been a system in place for patients
to be identified then this error might have been discovered earlier. Responding to the first story
(retraining the clerk using typical person approach to human error65) is unlikely to have as sustained an
effect as addressing the second story (or system) problems, such as having patients see a health
professional first, implementing mechanisms to assure all patients have been triaged, introduce a system
for checking code input, especially during busy periods – i.e. when for example more than 5 patients
arrive at the same time and when nurses have their handover, introduce a process of accounting for all
persons in the waiting area, particularly at times of shift change or handover, or involve patients in this
procedure, inform them and their relatives that they will be seen next for triage.
The use of narrative descriptions, tables or graphical representations of complex accident scenarios is a
communicative and analytic convenience, but has several drawbacks. It tends to make causal
connections seem clearer and the world more orderly than it is actually experienced by actors in a field of
practice; it also tends to make contributing conditions seem like discrete events, when they actually may
have developed insidiously66. An additional difficulty is that the two dimensional format forces some
factors to be in close physical proximity, which tends to suggest a close or important relationship that may
not exist, while others may have to be represented at some distance, which may erroneously suggest the
reverse.
A variety of methods for eliciting the deeper vulnerabilities that underlie the superficially apparent
“causes” of accidents and incidents are available. Textual, narrative descriptions are important in
creating understanding, but are sometimes difficult to follow, are not compact. This has led to a variety of
graphical methods of representation63,64,66,67. While these representations cannot stand alone, they seem
useful aids to narrative descriptions. In addition, they may prove particularly useful tools to accident
investigation teams, since they afford a method of recording events, vulnerabilities, violations and
influencing factors at the time they are suspected but before they have been fit into a coherent narrative
description. The ‘systems analysis’33 we have used here differs considerably from the standard root
cause analyses in the following ways: by showing complexity of the genesis of incidents; the use of
graphical representation; and providing a full exploration of contributory factors.
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5 Using Barrier/Safeguard Analysis to help improve patient safety within the medication process
5.1 Introduction
Whilst techniques that assess human reliability or error analysis have been well-accepted and integrated
into the safety management process in other industries, the application of such techniques to the problem
of risks in healthcare is rare. These techniques (collectively known as Human Reliability Analysis - HRA)
identify the errors and weaknesses in the system by examining the systems of work including those who
work in the system. The ultimate goal of HRA is to improve reliability and safety. The main influence of
human reliability approaches has been on the analysis of serious clinical incidents in healthcare, using
the critical incident technique68, root cause analysis69 and other methods70. In the last few years there
has been growing interest in a wider range of safety and reliability techniques used in other industries.
One technique that has potential in healthcare is Barrier Analysis.
Barrier Analysis has been used primarily by the nuclear and chemical process industries to reduce error
by looking at the barriers put in place to protect vulnerable objects from the hazard caused by the transfer
of harmful energy71. The term barrier can be inter-changed with the words control, defence or safeguard.
Barrier analysis considers what safeguards are present in a process to protect vulnerable objects or
individuals such as patients from harmful objects or actions, including healthcare treatment. There are
four main types of barriers: physical, natural, human action and administrative. Physical barriers block the
route of harmful energy to the vulnerable object, such as walls or a radiographer’s lead apron. Natural
barriers of distance or time are used to protect the patients or staff from harm, such as isolating an
infected patient or staff distancing themselves from an X-ray machine when in use. Human Action
barriers are procedures that remove the vulnerable object from risk of harm or reinforce other types of
barriers, such as checking the dose of a drug before administering it. Administrative barriers refer to
rules, protocols and training, such as the controlled drugs policy. Barrier analysis also considers the
respective strength of each barrier – that is, the degree to which they provide effective and reliable
protection from harm. In other words: Can these barriers be easily broken? And do they always work?
Once barriers and their strengths have been assessed, it is then possible to see what improvements are
required, whether to reinforce current barriers or to introduce new barriers. Cost and feasibility of any
improvements can then be considered and implemented.
Barrier Analysis can be used both retrospectively, to examine a particular incident, or prospectively, to
examine a specific process by looking at the possible risks associated with it and what barriers are
currently in place to protect the patient, staff or equipment in question.
Safety in Accident and Emergency Care
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The aim of this study was to show that prospective Barrier Analysis can be applied to healthcare using an
example from A&E.
5.2 An example of Prospective Barrier /Safeguard Analysis
Medication error is one of the most prevalent types of medical error. In hospitals, errors occur in 1.5% of
prescriptions72, and 4-8% of medication administrations73. Interventions such as computer order entry
have been shown to substantially reduce the rate of medication error74, but most interventions have been
directed at ward care. Here we consider the much more fluid and unpredictable environment of the
emergency department. The risk of “a medication prescription not checked by a nurse before being administered by a nurse” was
identified as a concern for the Accident and Emergency (A&E) department. To narrow the scope of the
process, all participants were asked to consider this event as occurring in the prescription and
administration of oral drugs in ‘majors’.
Method Team members consisted of 2 A&E Consultants, 1 Registrar, 1 Matron, 3 Emergency Nurse Practitioners
and a Senior Staff Nurse. They took part in this individually or in small groups depending on availability.
First they were introduced to the concept and process of Barrier analysis. Second they were then
presented with the medication administration problem and were asked to identify the barriers already in
place to prevent the above risk, the associated strengths and overall suggestions for improvements.
Once all of these had been collected from every member of the group, they were then asked to judge the
cost implications and identify the system or individual who would be responsible for implementing the
suggested changes.
Findings from the Barrier/safeguard analysis
Table 5.1 shows 13 barriers or safeguards identified by the A&E staff regarding the problem of “a
medication prescription not checked by a nurse before being administered by a nurse”. These are
grouped into the main types of barriers. No natural barriers were identified. Some barriers identified were
general such as ‘policies’ or ‘culture’, whereas others were specific, e.g. an ‘electronic pop-up warning on
a computer system’.
Safety in Accident and Emergency Care
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Table 5.1: Barriers or safeguards to prevent a dangerous occurrence: Prescription not checked by nurse before being administered
BARRIERS / SAFEGUARDS IDENTIFIED BY STAFF STRENGTH
Administrative Barriers
Electronic pop-up warning on a computer system Strong
Policies Strong /Medium/ Weak
Nurse’s code for administration – the 5 Rs * Strong/ Weak
Procedure of writing on prescription / signing off Medium
Procedures Weak
Requirement to look in policy booklet Weak
Culture Weak
Human Action Barriers
Doctor training – where nurses are responsible for teaching them and
therefore are more likely to check their own procedures
Strong
Any other colleague Medium
Supervision by Senior colleagues Weak
Patient questioning Weak
Training Weak
Physical Barriers
Drugs physically locked away where you can’t get them before you can
prove to another member of staff by showing the prescription
Strong
* the 5 Rs refers to: (1) the right medication (2) be given to the right patient (3) in the right dose
(4) by the right route (5) at the right time
Table 5.2 displays 16 improvements suggested by staff. These have been grouped into the following
categories: education and training; supervision and checking; feedback; resources; software design; and
cultural and organisational change. Each tick represents a judgement by each member of staff. There
was some disagreement regarding the costs for most, except for those relating to changing ‘undesirable
attitudes’, improving software systems or increasing staffing levels.
Safety in Accident and Emergency Care
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Table 5.2: Improvements suggested to prevent the dangerous occurrence:
Prescription not checked by nurse before administration
Costs Responsibility Improvements Identified By Staff
High Med Low NHS Trust Medical &
nurse
education
Prof.
body
Local
staff
Education and training
Further training for doctors in
administration practice
Allow an experienced nurse to
prescribe drugs (and thus shoulder the
responsibility themselves!)
Reinforce training
Supervision and checking
Supervised practise for junior staff
Double-checking by senior colleagues
Double-checking of charts by other
members of staff
Feedback
Feedback on practice and near misses
Rewarding good practice
Appraisals to address “undesirable”
attitude – e.g. Over-confidence
Resources
More written resources – on frequently
used drugs and doses / infrequently
used drugs and doses
Up to date written resources
Greater availability of written resources
Software design
Improved design of software systems
Cultural and organisational change
Change culture & behaviour
Question everything
Increase staffing levels
Safety in Accident and Emergency Care
32
When asked about responsibility of implementing the list of improvements, most staff considered these
improvements should be addressed at local level, though sometimes more than one section of the
organisation might be involved, particularly those related to education and training, or to cultural or
organisational change. Only one improvement, staffing levels, were identified by all staff as the sole
responsibility of the Trust. The Trust was also identified by at least one respondent as being partly
responsible for implementing nearly all suggestions for improvements.
5.3 Discussion
The results of this study show that the barrier analysis technique is feasible for application in a healthcare
setting. With a relatively small number of participants, a reasonable number of barriers and improvements
have been identified. Staff identified 13 barriers related to a prescription for oral medication not checked
by a nurse before being administered by a nurse in majors. The barriers elicited were mostly
administrative or related to human actions. There was discrepancy in the judgements of barrier
strengths, for policies and for the 5 Rs Nurse’s code for administration. The strength of barriers can be
defined in terms of its type e.g. physical barriers are generally strong, whereas administrative barriers are
weak75,76. Such staff perceptions of “strength” has important implications for Trusts when considering
what sorts of safeguards to put into place - particularly when barriers which are expensive to implement
or maintain are mistakenly thought to be strong. One solution might be to include the advice of a human
factors expert or someone experienced in barrier analysis following the data collection stage.
While the physical changes relating to software and staffing levels were thought to be costly, changes
relating to individual action or behaviour were thought of as inexpensive. For the recommendations
relating to ‘double-checking’ the judged costs spanned the full range. Improvements relating to the
individual, such as ‘question everything’, appraisals for over-confident staff, feedback, a change in culture
and behaviour were judged to have low costs. No obvious physical barriers or safeguards were
generated. This is further evidence that healthcare relies heavily on policies and procedures to manage
safety issues and when the system is pushed to the limit, the effectiveness of such barriers is clearly
compromised.
The response from those in a position to implement and drive change was extremely positive. In some
cases, the improvements suggested were already in place and this highlighted a need to disseminate this
information more effectively. For example, the request for “greater availability of written resources” had
already been addressed by providing this information on the computer systems. A further response was
to consider the safe practice of the medication process specifically within the in-house training schedule.
Within the department, this will now be a set topic within the nurse teaching schedule. In addition, the
process of prescribing and checking drugs is something that will now be emphasised during the doctors’
departmental induction.
Safety in Accident and Emergency Care
33
The fact that such improvements have been accepted so readily highlights another positive attribute of
the barrier analysis technique. Many of the improvements suggested were feasible within the practical
running of the department and were not idealistic requests for expensive or impractical solutions.
Furthermore, it was suggested that now the staff are familiar and comfortable with the no-blame
systematic concept of barrier analysis this could be followed with using retrospective barrier analysis to
look at which barriers failed (resulting in drug errors) and how they could be enforced or improved.
Safety in Accident and Emergency Care
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6 Communication patterns in Accident and Emergency
6. 1 Introduction Healthcare staff are accountable for between 60-90% of all information transactions in the healthcare
system77,78. Poor communication between healthcare staff can substantially contribute to medical
error2,12,13. In Australia, a retrospective review of 14,000 in-hospital deaths showed that communication
errors were the lead cause, and were held accountable for twice as many errors as inadequate clinical
skill2. Further, an incident monitoring study reported that communication problems were involved in 50%
of all adverse events79.
Interruptions in healthcare settings are ubiquitous. The ED in particular has been described as an
interrupt-driven healthcare environment. Findings from the United States and Australia have shown that
interruptions in work processes are frequent, occurring on average ten times per hour21-23. Furthermore,
healthcare staff often have to deal with two or more tasks concurrently22. These findings are of concern
for two reasons. Interruptions can disrupt memory and generate errors80; and multitasking may result in
memory overload, causing some of the information to be lost before processing is complete81.
In the study department, a senior nurse is allocated the “nurse in charge” role. This role encompasses
responsibility for the team of nurses and junior doctors for supervising, giving clinical advice, allocating
tasks and ensuring co-ordination of workload . In addition the NIC is expected to be aware of the clinical
condition of all patients in 5 areas of the department, to receive information from a number of sources
regarding clinical, operational and strategic events, process that information and relay it to other relevant
departments. He or she is also the receiver of non urgent information that might impact on future shifts, or
previous shifts which must be documented and acted upon. The nurse in charge works in the majors or
trolley cubicle area of the department where the coordination of patients is assisted by a white board list
of present case load. They also utilise paper records of other key information and carry a bleep. The
nurse in charge therefore has a pivotal role in ensuring the smooth functioning of this complex clinical
environment. Thus it is important to study levels and patterns of communication exchange in this
particular staff group.
In 2002 a method to measure communication patterns in the clinical environment was produced. The
method is based on previous research23,77,82 and is known as the Communication Observation Method
(COM). It provides a validated ethnographic (or structured observational) method in which to measure the
communication load of different healthcare staff83.
The primary aims of the present study were to use the COM to investigate the communication load of the
nurse in charge in an inner city London A&E department and to build on this method by collecting
additional information that would help us to interpret the data, such as patient throughput and staffing
levels. This supplemental material would be used to validate the communications, and to contextualise
Safety in Accident and Emergency Care
35
the shift in terms of workload. A secondary aim was to modify the COM to make it more user friendly and
time efficient.
6.2 Method Initials stages of the study Before data collection commenced, a pilot study was conducted to test the feasibility of the study and to
identify any potential methodological difficulties. We identified the following technical problems relating to
the recording equipment: tape recorder would get switched off accidentally whilst in the nurse’s pocket;
and the speech recognition function would get adjusted resulting in unintelligible recordings. These were
resolved by protecting these sensitive parts of the equipment with tape.
Participants Eleven nurses in charge of an inner city hospital A&E department were observed while they conducted
their daily nursing activities. The sample comprised two males and nine females of varying ages ranging
from 27-46 years old (mean 33.78, SD 5.65). Six nurses were G grade and the remaining were F grades.
Four nursing staff were observed more than once.
Data collection Prior to data collection a description of the study method was circulated to the nursing staff. This
information was also presented verbally by the researcher during the recruitment process. Data
collection took place over a 6 month period (January - June 2005) on a typical weekday between 9am-
6pm. A total of 20 hours of data were collected from 18 study periods of varying duration, ranging from
30-90 minutes.
Pre-observation data
After receiving informed consent, the researcher asked the NIC to ‘Describe briefly what your role will be
during the observation period?’. Demographic information was also collected.
Observation data
A lapel microphone was attached to the NIC, connected to a small tape recorder which was placed in
their pocket. The researcher shadowed the NIC for an agreed duration, taking field notes on the NIC’s
activities throughout the observation. The NIC was able to suspend the recording at any time or to
exclude information from the recordings retrospectively.
Modifications to the COM data collection process
A number of post-observation questions were asked: 1) ‘Were there any unnecessary communications?’;
2) ‘Were there any unresolved communications?’; 3) ‘What was the most annoying thing about this time
period with respect to communication?’. The NIC was also asked to indicate from a checklist any
potential problems (e.g., with equipment, mislabelled specimens) during the recording period; and to
clarify the nature of any observed CE’s which were not completely clear to the researcher at the time of
Safety in Accident and Emergency Care
36
recording.
Data on medical and nursing staffing levels of different A&E staff on duty at the time of the recordings
were collected (i.e., consultants, senior house officers, registrars and nurses) and information on patient
levels were gathered.
Data analysis Data were collected in accordance with Coiera et al’s Communication Observation Method83. The
researcher’s field notes were transcribed and were used in conjunction with the tape recording to identify
individual communication events (CE’s). The purpose of communication, communication channel, and
interaction type were ascribed for each CE83 (see appendix A for further information).
Modifications to the COM data analysis process
For the purpose of the present study the following modifications were made to Coiera et al’s
methodology: 1) additional channels of communication were included (see table 6.1 for the full list); 2)
‘study’ and ‘equipment’ subcategories were added to the ‘purposes of communication’ list. The
subcategory of ‘patient management’ was adjusted to include all aspects related to patient care (e.g.,
administer medications, get test results, diagnosis and suggested treatment modality, attending to
patients pain); 3) the term ‘greeting’ under the ‘interaction’ category was renamed ‘general’ and
encompassed general conversational communication (e.g., greeting, thanking, apologising); 4) the term
‘3rd party interruption’ was used to explain a CE (face-to-face, telephone) that was initiated by a third
party, occurring whilst the NIC was already involved in a synchronous CE. We maintained Coiera et al’s
definition of an ‘interruption’: when communication was initiated by someone other than the NIC.
6.3 Results Pre observation information to elicit the NICs’ views on their workload before observation were collected
on 17 of the 18 recordings. On one occasion the NIC was too busy to answer the question.
To the pre-observation question ‘Describe briefly what your role will be during the observation period?’
the NIC provided general responses of their duties: 4 described their role in relation to management of
the department only; 5 as management of staff and department and 8 included three aspects of their role:
management of A&E, staff management and patient management. In addition, specific tasks the NIC
needed to carry out during the recording that would not usually form part of their everyday workload were
mentioned on 2 of the 17 observations. These consisted of: dealing with a patient that required a psych
liaison nurse; trying to sort out difficulties with the heating in Majors; and problems with the PODS (the
vessel in which haematology samples get placed to be sent through to the relevant department, e.g.,
haematology/microbiology).
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Communication load We identified a total of 2019 distinct CE’s. 1183 (59%) were initiated by the NIC. Communication
multitasking (e.g., talking to someone and writing on the whiteboard) was evident on 286 (14%)
occasions. This was in addition to any other concurrently active tasks that did not involve communication
of any form (e.g., filing, handling equipment). The NIC was interrupted (i.e., other person initiated the
conversation) on 836 (41%) occasions. There were 47 (2%) third party interruptions, where a person
interrupted an on-going synchronistic communication event.
Recordings were suspended by the NIC 6 times on 5 separate observation periods. Reasons for
suspension were due to confidential discussions with members of staff or patients.
Type of CE’s A total of 19 different communication channels were identified (see table 6.1). Synchronous
communication (N = 1672), accounted for 83% of all CE’s, with face to face communication and
telephone conversation occurring on 1528 (76%), and 144 (7%), of occasions respectively.
Table 6.1: Type of Communication Event
Type of Communication Channel Number of CE
Face to face* 1528 (76%)
Telephone* 144 (7%)
Computer 107 (5%)
Whiteboard 104 (5%)
Pager 35 (2%)
Patient records 35 (2%)
4 Hour Target 19 (1%)
Paper source 14 (1%)
Tannoy 7 (<1%)
Staff Allocation Sheet 6 (<1%)
Off Duty 5 (<1%)
A&E activity Sheet 4 (<1%)
Patient Transport form 3 (<1%)
Agency Form 2 (<1%)
Message Book 2 (<1%)
Evacuation Form 1 (<1%)
Booking Request Form 1 (<1%)
Incident Reporting Form 1 (<1%)
Emergency Form 1 (<1%)
* Synchronous communication channels
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Purpose of CE Eight distinct task communication purposes were identified (see table 6.2). 961 (48%) CE’s were
concerned with patient management.
Table 6.2: Purpose of CE
Purpose of CE Total
Management of the Department 961 (48%)
Staff Management 362 (18%)
Patient Management 327 (16%)
Administration 112 (5%)
Equipment 102 (5%)
Social 72 (4%)
Study 64 (3%)
Education 19 (1%)
Interaction type The majority of interactions involved the NIC giving information (e.g., to another person, writing on the
whiteboard, typing on the computer) or the NIC asking someone a question; accounting for 546 (27%)
and 465 (23%), respectively (see table 6.3). Of the remaining CE’s, 428 (21%) involved the NIC being
asked a question (e.g., ‘is the patient in cubicle D going home?’), 380 (19%) involved the NIC being given
information (e.g., ‘Patient in cubicle C is going to CDU’), 117 (6%), concerned the NIC instructing an
individual to perform a task (e.g., ‘ please can you keep an eye on the patient in cubicle E’s blood
pressure?’), 68 (3%) involved ‘general’ synchronous communication (e.g., ‘hello’) and, lastly, only 15 (1%)
involved the NIC being instructed to perform a specific duty by another person (e.g., ‘please can you give
these keys to the occupational therapists when you see them?’).
Table 6.3: Communication interaction type
Interaction Type Total
Giving information 546 (27 %)
Give request 465 (23 %)
Receive request 428 (21 %)
Receiving information 380 (19 %)
Instruct request 117 (6 %)
General 68 (3 %)
Instruct receive 15 (1 %)
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Post observation data Eleven of the 17 nurses questioned stated there had been no unnecessary CE’s during the time of
recording. Four nurses said that there had been unnecessary CE’s though none of them elaborated on
this any further. Out of the remaining two nurses, one did not answer the question and another could not
answer the question as the A&E department became too busy and they were needed elsewhere.
In response to the question concerning unresolved CE’s, eleven nurses reported there had been no
unresolved CE’s (the remaining six nurses provided no response). However, from this sub-group the field
notes and recording providing evidence to show that where were in fact 3 unresolved CE’s out of the 11
recordings. Specifically, these concerned the incompletion of a CE due to the NIC being interrupted: 1) by
a sister whilst having a conversation with a junior sister; 2) by a SHO whilst having a conversation with a
nurse; 3) by a member of admin staff whilst in discussion with a sister. For example, the NIC is
explaining to the junior sister about what is happening with the patients that are in majors that are soon to
be breach (i.e., whether they will be discharged or admitted). The NIC tells the junior sister that there are
three beds on CDU. The NIC is then interrupted by a nurse who informs her that he has patient X’s notes.
The nurse asks the NIC whether she wants the patient’s notes. The NIC tells the nurse that patient X has
gone to CDU and asks whether he could take the patient notes over to CDU. The NIC does not go back
to the previous conversation with the junior sister (for the duration of the recording) about the patients that
are about to breach in Majors.
With regards to the question ‘What was the most annoying thing about this time period with respect to
communication?’ data were collected from 14 nurses (the remaining 4 nurses were too busy to answer
the question). From this sample a common recurring problem that they had too may things to deal with at
once (N=8; see table 6.4) grouped into general and specific responses.
Table 6.4: NICs’ (verbatim) self-report post responses on the most annoying thing (regarding communication) during the observation period
General responses Specific responses
Trying to deal with too many things at
once
Trying to do with a phone call to NHS
Professionals during which time many different
people spoke to me
Trying to do two things at once
Talking to a member of staff whilst on the phone
at the same time
There was a lot of things going on at
once
Trying to ensure the efficient running of all the
sub departments of A&E simultaneously
Having to deal with lots of different things
at once
Having to deal with two phone calls at once
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In addition, in 4 of the 14 observations, the NIC reported a communication problem that specifically
related to the given observation period (i.e., a communication problem that would not be a typical
occurrence on a daily basis). Responses (verbatim) were; ‘problems with trying to sort out an account cab
to take a patient to another hospital’; ‘heating problems’; ‘having to wait for the porter to take a patient to
the ward (the patient was getting irate)’; ‘an ex-patient kept ringing up the A&E department and was being
very awkward’.
In addition to the above responses, on 2 out of the 14 observations the NIC stated that there was
‘nothing’ annoying (i.e., no more than usual) about the recording period with respect to communication.
Staff levels Data were collected for the number of nursing and medical staff on duty in the ED and was considered in
relation to the mean number of CE’s to ascertain whether staff levels had an effect on communication
levels. This was examined by using the range of the mean number of CE’s per minute for each
observation that had the same number of staff for each profession working (e.g., the CE range for all
observations that had, for example, 4 SHO’s on duty; see Table 6.5).
There were no relationship between the number of Consultants on duty and the mean number of CE’s
observed, r17 = 0.248, ns; and between the number of nurses on duty and the mean number of CE’s
observed, r17 = 0.423, ns. However, there was a moderate relationship between the rest of the medical
staff working during the observation period and the mean number of CE’s observed: r17 = 0.469, p ≤ 0.05
and r17 = 0.526, p < 0.05, for Registrars and Senior House Officers (SHO’s), respectively. This
relationship shows that the more junior medical staff on duty the greater the number of communication
events.
Patient levels Table 6.7 displays the total number of patients that were in the A&E department during the data collection
period. The number of patients who left the department during the observation period is also provided
including: those who arrived after the observation commenced and left before the observation finished;
and those who were already in the department and left during the observation period.
A Spearman’s correlation revealed a moderate relationship between the number of patients in the
department and communication load: the greater the total number of patients in the department, the
greater the number of CE (r17 = 0.628, p < 0.01).
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Table 6.5 The range of Communication Events per minute for the different numbers of medical and nursing staff on Duty
Number of staff on duty Number of observations
Range of no. of CE per minute
Consultants
2 2 1.78-1.85
3 6 1.64-2.18
4 5 1.23-1.96
5 5 1.32-2.12
Registrars
2 10 1.23-1.96
3 1 1.6
4 7 1.51-2.18
SHOs
2 1 1.23
3 3 1.32-1.96
4 4 1.24-1.85
5 2 1.73-2.18
6 2 1.51-1.78
7 1 2.12
8 3 1.64-1.96
11 1 1.89
Nurses
17 2 1.56-1.85
15 1 1.24
14 1 1.32
13 7 1.51-1.96
12 5 1.23-2.18
11 1 1.96
10 1 2.12
Further correlations were then conducted to explore whether there was a relationship between the
number of patients that left the department during the observation period and the mean number of CE’s
observed. The results revealed no significant relationships r = 0.124, ns.
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Table 6.7: Patient levels during the observation period
Date of
observation
1. Number of
patients who
arrived during
the
observation
period
2. Number of
patients already
in the
department
when the
observation
commenced
Total no.
of
patients
present
or arriving
3. Number
of patients
who left the
department
Total in A&E
at time of
observations
Mean
CE
duration
in
minutes
No. of CE's
per minute
(total CE's
observed ÷
duration of
observation)
25/02/2005 11 15 26 3 23 0.46 2.18
09/06/2005 20 25 45 18 27 0.47 2.12
20/06/2005 33 19 52 17 35 0.51 1.96
22/06/2005 13 44 57 17 30 0.51 1.96
22/03/2005 17 25 42 12 30 0.52 1.91
02/03/2005 11 31 42 13 29 0.53 1.89
21/06/2005 13 19 32 7 25 0.54 1.85
01/06/2005 28 11 39 19 20 0.56 1.78
02/06/2005 20 18 38 14 24 0.58 1.73
31/03/2005 19 10 29 8 21 0.58 1.73
18/02/2005 6 27 33 11 22 0.61 1.64
12/04/2005 14 6 20 3 17 0.62 1.63
03/03/2005 5 22 27 7 20 0.63 1.60
15/06/2005 28 11 39 14 25 0.64 1.56
24/01/2005 15 29 44 15 29 0.66 1.51
12/05/2005 13 10 23 12 11 0.76 1.32
23/06/2005 23 14 37 16 21 0.80 1.24
14/06/2005 17 8 25 12 13 0.81 1.23
6.4 Discussion
Our study showed that the senior nurses in charge of A&E had to deal with high levels of information
exchange as part of their daily working activities, with a new CE occurring on average every 0.59 minute
(36 seconds).
In accordance with previous research13 staff members in A&E seem to favour synchronous
communication channels (i.e., talking face-to-face or via the telephone) when talking to the NIC, as
opposed to asynchronous communication channels (e.g., whiteboard), which accounted for 83% (n =
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43
1672) of all CE’s. On 836 (41%) occasions synchronous communication was initiated by someone other
than the NIC. This is similar to Coiera et al.’s findings, that interruptions in A&E healthcare staff
accounted for 30.6% (n = 393), of all observed CE’s13. In addition, third party interruptions accounted for
2% (n = 47) of all communication events.
Based on our results we feel that the number of times in which the NIC was ‘interrupted’ could pose
salient implications for the effective exchange of information. If the NIC is distracted from what they are
doing (e.g., writing on the whiteboard), this may disrupt their thought process, which in turn, could have
adverse effects on the quality and completeness of the previous intended message.
Communication multitasking (i.e., the NIC conducting two CE’s simultaneously) was observed on 286
(14%) occasions. This together with other concurrently active tasks that the NIC was involved in (i.e., that
did not involve communication of any form), could be a serious threat to the effective exchange of
communication between the NIC and healthcare staff. This view is based on research which suggests
that several concurrent tasks may disrupt memory because the number of items that can be held in
working memory is small81.
There is a significant need to reduce the sheer volume of communication load that the NIC has to deal
with on a daily basis. Future research could investigate the following: potential methods in which
communication, particularly synchronous communication, can be reduced for the NIC; and specific
strategies to lower the number of times that the NIC is ‘disturbed’ or ‘interrupted’ from what they are
doing. These could include better integrated IT systems to reproduce paper data collection and require
documentation only once, use of texts and emails rather than phone calls, and support for senior nurse
by task analysis and role redefinition. In addition training the senior nurses for communication capacity,
time management and delegation may reduce the number of interruptions.
We feel that the efforts and resources to undertake such work would be modest in comparison to the
benefits that the findings could have to patients, health professionals and the health system as a whole.
Improving communication between healthcare staff by reducing the levels of interruptions and minimising
the volume of irrelevant or unnecessary information exchange could therefore have important implications
for patient safety.
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7 Evaluation of the Triage Process
7.1 Introduction
In A&E triage refers to a process of assessing incoming patients to the most appropriate care pathway
according to the urgency of their symptoms or preliminary diagnosis. In some cases, this may involve
treatment in the triage area and/or being sent to another healthcare provider outside of the emergency
department – a process known as “see and treat”. In many cases, the triage process not only evaluates
patients but also facilitates the efficiency of the care process within and beyond the emergency
department by foreseeing the need for tests or the care of particular specialties and initiating these from
triage.
There have been a number of attempts to impose time restrictions on A&E processes to ensure that
those needing urgent care receive timely intervention. In 2000 the DoH announced in The NHS plan that
“By 2004, no-one should be waiting more than four hours in accident and emergency from arrival to
admission, transfer or discharge”8. and the promise to patients laid out in “Your Guide to the NHS” 84 that
on arrival in A&E “you should be assessed by a nurse or doctor, depending on how urgent your case is,
within 15 minutes of your arrival…”. As well as these policies, the requirements of the triage task itself
impose a degree of time pressure on the triage staff. They must spend adequate time collecting
information from the current patient to make the best possible triage decision but also not delay those
waiting in reception who are, as yet, of unknown criticality.
A number of studies have examined the nature and effectiveness of the triage process. In the US,
Paulson85 carried out a retrospective review study of the impact of nurse qualification level on triage
waiting time. Within this, time to triage (defined as the time from sign-in to the start of triage) took an
average time of 17 minutes for a licensed nurse (data from 1998) or 15 minutes for unlicensed assistive
personnel. The time from triage to treatment was significantly reduced (from 127 to 54 minutes) when the
more qualified nurses were responsible for triage. Thus the minimal time saved in the wait for triage by
using less-skilled staff greatly reduces the efficiency of the overall care process. Lindley-Jones &
Finlayson demonstrated that when x-rays were ordered by triage staff, walking wounded patients were
treated quicker without compromising service quality86,87. The inclusion of extended skills in the triage
nurse from “test ordering” to full “See and Treat” offers further potential for greater efficiency, though
potentially at the cost of causing an influx of GP patients causing stress and overwork for the A&E staff88.
Issues of efficiency, quality (accuracy of judgement) and role definition in triage have not yet been fully
and objectively assessed or evaluated. Simmons89 suggested that to be able to implement any changes
in A&E, for them to have the desired effect on quality and efficiency, it would be necessary to support
these with changes throughout the healthcare system as triage is but a small part of total patient
pathway. A study by Locker and Mason90 looked at the total time in the department of a large cohort of
patients from all over the UK, and mapped the frequency distribution of total times. Whilst a
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45
disproportionate number of patients appeared to leave the department immediately before the 4 hour
target time there were also many others with long times. However, from the data supplied, it cannot be
established the reasons behind some of the long attendances or any bottlenecks in the system. For this
reason, looking at the fine detail of triage using a systems approach provides an objective non-
judgemental evaluation of the efficiency and or effectiveness of a process to identify potential early time
saving process issues but at the same time, keeping the people who carry out the work involved in
defining the current tasks and work environment as well as identifying realistic solutions to the problems.
The aim of the study was to evaluate the efficiency of the triage process from a systems perspective
using tools from human factors. It is a two-phase study incorporating a task analysis and ethnographic
study. Verbal consent was obtained from both staff and patients for the study and patient confidentiality
was attained through independent coding of data.
7.2 Methods
97 patients were observed being triaged in the waiting room triage area over 11 days from August to
October 2004. They were seen by 12 different triage staff (five E grades, two F grades, two G grades, two
ENPs and one consultant physician) to develop the task analysis (see appendix B) and study protocol.
For the ethnographic study, 258 patients were observed for their attendance in the in the waiting room
triage area sampled during day-time triage sessions over a period of two months (Jan/Feb 2005).
Measures
For each patient, the following information was recorded:
• Time from registration to being called for triage
• Time for the duration of triage
• Time spent alone within triage
For each member of staff, the following information was taken:
• Length of triage session observed
• Number of patients triaged within observed period
• Time absent from the triage booth within observed period
• Grade of triage staff
Procedure
Sixteen hours of observations in triage and 12 interviews were carried out with 12 nurses, two ENPs and
an Emergency department consultant physician who were all experienced at triage. Using the task
analysis processes described in Kirwan & Ainsworth91, these data were used: to produce and agree a
generic representational flowchart for the triage process (see Appendix B), to prioritise the relevant issues
Safety in Accident and Emergency Care
46
to triage efficiency and patient safety; and to develop a list of measures as a protocol for the ethnographic
study.
For the ethnographic study, data were recorded in the triage area for over 1882 minutes, on 16 different
members of staff carrying out the triage task on 258 patients
7.3 Results The mean time that patients waited from being registered on the computer in reception to entering the
triage booth was 13 minutes 33 seconds (n=246). This included six patients whose triage was delayed
because they were not in the waiting area when called into triage.
The mean time for all data to triage a patient – from entry to the triage booth to departure was 4 minutes
and 19 seconds (n=247).
Significant differences were found in the times taken to triage a patient between the areas to which a
patient was triaged, Kruskal-Wallis χ2 = 25.026, p ≤ 0.001, as well as the persons responsible for their
care, χ2 = 18.738, p ≤ 0.001. There was a significant difference between those triaged to A&E staff in
Majors and A&E staff in Minors, Mann-Whitney U = 2701.50, p ≤ 0.02.
There was no significant difference between those triaged to the A&E staff in Minors or the ENP, Mann-
Whitney U = 825.000, ns, the GP within Minors or the patient’s own GP, Mann-Whitney U = 7.5, ns.
Furthermore, there was no significant difference between those “seen and treated and sent home” and
those “advised to see alternative care providers”, Mann-Whitney U = 59.5, p ≤ 0.397.
There was a significant increase in the time it took to triage to a specialty working within the department
from that taken to triage a patient to majors, Mann-Whitney U = 289.5, p ≤ 0.01, but no significant
difference to triage a patient to an alternate care provider than to triage to an internal specialty, Mann-
Whitney U = 79.5, ns. There was a significant increase in triage time for those triaged to the responsibility
of specialty staff compared with those triaged to the responsibility of A&E staff, Mann-Whitney U =
1077.5, p ≤ 0.001. Together, these tests suggest that any contact with a speciality, regardless of where
the patient is to be seen, results an increase in triage time. There was no significant difference in triage
time between those patients who were triaged to different areas but whom were all to be seen by
specialty staff, Kruskal-Wallis χ2 = 2.555, ns.
Five (2%) of the 247 patients arrived in the triage area with all the paperwork consistent with a specialty
referral but the specialties did not accept responsibility of the patient. In this case, the triage requires all
the time involved in a specialty referral but the patient was triaged into the Emergency department. Within
this study, there was an overall increase in the time to triage patients that were deemed as requiring
specialty care, Mann-Whitney U = 1795, N=28, p ≤ 0.001, but no difference in triage time as to whether
Safety in Accident and Emergency Care
47
the specialties accepted or refused, Mann-Whitney U = 47, ns. This confirms that it is the communication
required with specialties in the process that impacts on the triage time – irrespective of the outcome.
There were 34 patients who were “Seen and Treated” in triage, including those who were advised to see
their own GP. There was no significant difference in the time taken to “See and Treat” patients from
triaging into the department, Mann-Whitney U = 3022, ns. This seems unlikely to have an overall negative
effect on the running of the triage process. In many cases, the active “See and Treat” was carried out
when waiting times were low and the triage / reception area was clear.
The “rate” of triaging patients was on average 8.4 patients triaged per hour (one patient every 7 minutes
and 8 seconds including the necessary time of preparation between patients). There was no difference
between staff grades or individual staff member, χ2 = 3.187, df = 4, ns, χ2 = 18.318, df=15, ns,
respectively.
7.4 Discussion
This study has highlighted some important issues in the management and implementation of the triage
process.
The mean time that patients waited to be seen for triage was 13 minutes 33 seconds. This is close to the
15 minutes national target and is similar to Paulson’s85 research where the mean wait time for triage was
13.71 minutes. However, unlike Paulson’s study, the difference between grades was not reflected in our
study. On average staff took 4 minutes and 19 seconds to triage a patient. For patients who were
expected by specialties and/or triaged to specialties, the triage process appeared longer. This process
generally required supplementary phone communications. Furthermore, this did not seem to be
compensated by the fact that, if expected by the specialty, the tests and vital signs had already been
carried out by a GP and they were clinically easier to sort as their pathway had been pre-determined.
This study supported Lindley-Jones & Finlayson’s86,87 findings that ordering x-rays appears to be efficient
use of time and did not have any significant impact or detriment on the time to triage. Only a few patients
(n=6) were actively “seen and treated” in the triage area. This had a significant impact on the triage time.
While this was carried out when there were few patients waiting to be triaged, consideration might be
given to introducing guidelines when this could be optimally carried out for the benefit of more patients
without jeopardising the recommended 15 minute waiting target time for other patients.
Within this study, the time data relied on the output of the triage computer giving time data in ‘minutes’
rather than the more accurate ‘seconds’. This could also facilitate the examination of more detailed
features of the triage task by carrying out a time-line analysis, i.e. knowing how long individual tasks take
and whether they can be carried out in parallel would inform us whether certain tasks should be carried
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48
out in triage or whether this is to the detriment of the current as well as subsequent patients. Similarly, a
broader sample including patients at night-time and weekends would be more representative.
In this study, it was apparent that staff overcame a whole range of problems, including language
difficulties, patients presenting with an inappropriate history or interruptions from other staff, visitors or
other patients that interfere with the efficiency of their tasks.
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8 Conclusion
We have learned a great deal about the difficulties of studying emergency care and, we hope, made
progress towards improving our understanding of how better to study it. We view many of the issues
outlined in this report particularly in chapter 2 as difficult, but manageable, especially if they can be
anticipated in project planning, rather than reacted to as surprises during execution. This report illustrates
the range of studies summarised below.
The incident reporting study described in Chapter 3 showed that there were more near misses and minor
events reported in the dataset than those judged to be serious or moderate. The largest group of
reported incidents reflected problems of delay in A&E. This was due to various factors including the fact
that A&E depends on other departments, specialist and staff not based in A&E, such as porters. The
reporting process had several good aspects including a regular systematic review by the departmental
clinical risk management team and feedback in the form of newsletters. The findings of this evaluation
have been presented to the staff stressing that incident investigation analysis results in identification of
what, how and why an incident occurred92.
Retrospective case analysis as illustrated in Chapter 4 remain important in their contribution to our
understanding of adverse events and near misses. Furthermore, while textual, narrative descriptions are
important in creating understanding, they are sometimes difficult to follow especially when cases are
complex resulting in necessarily lengthy narratives. The range of graphical methods of
representation63,64,66,67 are useful aids to these descriptions and are obviously beneficial for both by
clinicians and researchers. In particular these methods can assist in reassuring clinical staff of the various
factors that contribute to the risks of any incidents they may be involved in.
In Chapter 5 we showed that there are many benefits to conducting a prospective barrier/safeguard
analysis including the structured format of the technique which can generate creative solutions to
problems. We have shown that barrier analysis, a method of error reduction used in other industries, can
be successfully adapted for healthcare. There are still some areas where training for this method could be
improved. For example, in relation to the identification of physical safeguards for reducing the risk of harm
to the patient. This is further evidence that healthcare relies heavily on weak barriers such as policies and
procedures to manage safety issues and when the system is pushed to the limit, the effectiveness of
such barriers is clearly compromised. Barrier analysis has also been developed by the NPSA and is
likely to be widely used in the future93. The formal process of barrier analysis can be lengthy and time
consuming, though the results repay the time invested. An additional potential benefit is that staff may
start to naturally consider barriers in their work – which could have a positive effect on practice as well as
safety culture.
The communication study described in Chapter 6 showed that the nurses in charge of A&E had to deal
with high levels of information exchange as part of their daily working activities. The number of times in
which the NIC was ‘interrupted’ has potentially serious implications for the effective exchange of
Safety in Accident and Emergency Care
50
information. If the NIC is distracted from what they are doing (e.g., writing on the whiteboard), this may
disrupt their thought process, which in turn, could have adverse effects on the quality and completeness
of the previous intended message. There is a significant need to reduce the sheer volume of
communication load that the NIC has to deal with on a daily basis. Improving communication between
healthcare staff by reducing the levels of interruptions and minimising the volume of irrelevant or
unnecessary information exchange could therefore have important implications for patient safety.
In Chapter 7 we evaluated the efficiency of the triage process. The mean time that patients waited to be
seen for triage was 13 minutes 33 seconds and the triage process on average took 4 minutes and 19
seconds. Furthermore, the triage process appeared longer for patients who were expected by specialties
or triaged to specialties. This study supported previous findings87 that ordering tests such as x-rays
appears to be efficient use of time and did not have any significant impact or detriment on the time to
triage. Only a few patients were actively seen and treated in the triage area, and though this took longer
compared with those ‘triaged and not treated’ it obviously was beneficial for the individual patient and the
fact that they would not need to be treated by staff in other areas of the department, namely minors.
Clinical implications
These exploratory studies have provided us with further insight into conducting safety research in A&E as
well as helped to build a mutually beneficial partnership with the clinical staff thereby attempting to
address some of the issues described in Chapter 2. In particular some of the studies have contributed to
changes, such as the piloting of an electronic incident reporting system. Early impressions suggest that
there has been an increase in the number of reported incidents using this new system. This has obvious
implications for clinical risk management in that the more incidents that are reported the more we can find
out about the nature and frequency of such incidents, especially as in healthcare not all incidents are
reported58. This will then have other knock-on effects such as a better understanding of the underlying
factors that contribute to incidents and near misses, enabling management and senior staff to make more
informed decisions about which changes to implement to improve patient safety. This together with the
staff experiences of the barrier analysis process can help them to identify solutions to problems and
factors that have led to could potentially lead to incidents and near misses in the future.
The ethnographic studies of communication with the nurse in charge and the triage process also have
implications regarding patient safety. We have already mentioned how the sheer level of communication
events needs to be reduced, particularly with the level of interruptions that will distract the NIC from
completing a task, including relaying information or making decisions regarding the management of
patients. Similarly in triage dealing with other specialties seemed to add to the work load and subsequent
triage time for patients. This has important implications to the overall four hour targets as well as for the
15 minute waiting targets for triage, particularly for other patients who are not expected by particular
specialties.
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51
Future research
One of the problems identified in chapter 2 was the lack of permanent traces of work can be mitigated in
some cases by judicious use of technology. Technology can be used in other areas of A&E to enhance
efficiency as well as some of the specific difficulties related to documentation for study. For example, the
status board which represents current work in minors, which although this physical artefact is ephemeral
(i.e., information is erased once a patient has left the department – whether admitted or discharged), it
can be captured using a small video camera, for example, and reviewed off-line. Cook (personal
communication) has suggested that the problem of the rapid time scale in the A&E might be handled by
progressively moving from slower-paced to more rapid environments; for example, from the operating
theatre, to the Intensive Care Unit, to A&E. In this way, researchers could build their observational skills
in a relatively easier setting, and then move on to more difficult situations. This sort of skill building would
require time, sustained commitment, and the development of good working relationships in multiple
departments of the hospital. Another example of a technological intervention is information provided for
staff. The efficiency of the triage process (and other areas of A&E) could be enhanced by providing
supplementary information required by the staff, such as maps, addresses of other clinical centres, bleep
numbers, information from the British National Formulary or Guy’s Hospital poisons unit in a
complimentary format, such as incorporated into the current computing system. It is possible that these
alternative sources of information may contribute to fewer interruptions to the NIC.
Table 8.1: A summary of lessons learnt and options for further research for each area studied
Area Key lessons learnt Options for further research workIncident reporting Retrospective analysis of incident
patterns helps enhance the reporting system and raises awareness
Compare to National data Electronic reporting in place and will be
reviewed Monitor effect of raised awareness on
the prevalence of certain incidents Incident analysis Use of graphical representation of
contributory factors is a useful additional tool developed to assist in analysis of incidents
Assess effect of using tool on staff understanding of safety
Barrier analysis Barrier analysis is applicable in healthcare
Conduct barrier analysis on high risk areas identified from incident reporting review
Communication load Senior clinical nurse working in the department has excessive communication load which may impact on effectiveness
Develop additional systems to redirect unnecessary communications
Triage process The process of initial assessment is made more inefficient by geographical issues, and non-clinical tasks
Monitor the effect of electronic handover at triage, using non clinical staff in different ways
Look at effectiveness of time spent in initial assessment on total time in department and reduction of clinical risk
Safety in Accident and Emergency Care
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Future research in A&E would incorporate our understanding and build on the studies described in this
report (see Table 8.1). In particular we have already starting looking at staff attitude to incident reporting,
staff perception of board rounds (A&E equivalent of ward rounds) and unscheduled returns to A&E. We
plan to undertake research in clinical decision making, particularly with respect to specific presentation of
symptoms, and factors that affect diagnosis. Despite the various challenges we experienced we have
succeeded in conducting various research projects and have built positive working relationship with the
staff who are keen for us to continue to conduct research in this field. Furthermore as indicated in
chapter 5 staff responded positively to recommendations that were elicited from these projects. The
implementations of any changes would necessarily require the endorsement of senior staff and staff in
general are likely to accept change when they see how it could have beneficial consequences.
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Appendix A Table A1: Channel and purpose of communication Channels of communication Purpose of communication Channel Acronym Purpose AcronymFace to face FF Management of the Department MD Telephone T Staff Management SM Computer C Patient Management PM Whiteboard WB Administration A Pager P Equipment E Patient records PR Social S 4 hour target 4 Study STY Paper source Paper Education ED Tannoy TNY Staff allocation sheet SAS Off Duty OD A&E activity sheet A&E Patient transport form PTF Agency form AF Message book MB Evacuation form EF Booking request form BRF Incident reporting form IRF Emergency form EF Table A2: Interaction type Interaction type Description Acronym Give request A request for information by the subject, that
is, the subject is asking for information GR
Receiving information Receipt of information by the subject RI Receive request Receipt of a request by the subject, that is,
the subject is being asked for information RR
Giving information Sending information from the subject GI Instruct request A request for action by the subject IR Instruct receive Receipt of instruction for action by the subject IRCV General Any communication which does not relate to
any of the above, e.g., greeting, thanking, apologising.
G
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Appendix B: Generic top-level task analysis of triage process
2. Call patient
4. Verify information on patient shown on computer is correct
1. Click on patient details
6 Enter/check information on computer (during process as required)
9 Examine observable signs (if appropriate) (examine wounds, bruises)
7 Elicit more information on problem ( pain?, vomiting?, known cause?)
8 Collect additional patient information (on medication? diabetic? pregnant? allergies?)
10. Look at additional information (documentation) if available (letters from GP, old ECG)
11. Contact specialty (if required) (contact medics,/ surgeons, gynaecology)
12. Perform additional tests (investigation) if appropriate
13. Order other tests (if required) (x-ray, blood, urine)
14. Offer and give painkillers (if appropriate)
15. Treat (dress wounds / give advice) (If appropriate)
16. Direct / Take patient to next area (A&E / clinic / home)
3. Ensure patient is reassured
5 Elicit key information on problem from patient (ask “what brings you here today?”)
TIME
top related