‘The need of regular treatment’ was the clinical condition that required regular procedures. ‘No need of hospitalisation’ was defined as a clinical condition that did not require hospitalisation or was not expected to have any major adverse effect if patients were not hospitalised. ‘A different disease’ meant a different disease was diagnosed in the second visit that was not clinically associated with that of the first visit. ‘Disease process’ meant a condition due to a disease factor itself, not due to a physician's error. We excluded the following conditions that were not considered a physician's factor (responsibility). In cases of disagreement, the two EPs met to reach a consensus or consulted with a third EP. After the interview and collection of any relevant data by two assistants, two EPs independently evaluated the return visit cases to determine if the cases had CSAEs and the causes of the CSAEs. Objective evaluation of CSAEs by senior EPsīecause of the possibility of inadequate documentation in the first visit chart, we checked and confirmed the opinion of EPs who saw patients in their second visits. We collected cases of return visits within 3 days daily at regular intervals (8:00, 20:00 and 24:00), using the hospital's patient computer database, which is updated in real-time. The main outcome measures were the EPs' subjective reasons for discharging patients with CSAEs, and an objective analysis of inadequacies in the BMP model such as those involving history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment of patients with CSAEs. This study was divided into two parts: a prospective investigation based on ‘on-duty EPs' subjective reasoning for discharging patients with CSAEs and without CSAEs’, and a retrospective analysis using ‘objective evaluation of CSAEs by senior EPs’ ( figure 1). From 1 September 2005 to 31 July 2006, we conducted a combined prospective follow-up and retrospective review study. All participating physicians signed a consent form agreeing to be interviewed before being enrolled. The study was conducted at a university-affiliated teaching hospital with an annual ED census of over 82 000 in Taiwan, and the protocol was approved by the institutional review board of the study hospital. 4, 9 We based our observations on EPs' subjective reasoning for discharging patients and senior EPs' objective evaluations. CSAEs included major operative conditions, major medical conditions, significant deterioration of clinical conditions and prolonged hospital stay (>3 days). Therefore, in this study we investigated the EPs' reasons for discharge of patients with clinically significant adverse events (CSAEs). Therefore, it would seem to be more useful to recommend that on-duty emergency physicians (EPs) undertake more detailed documentation of patient history, physical examination and medical decision making to prevent adverse events than to try to change the thresholds of the basic management process (BMP).
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3 Knowledge-based cognitive behaviour involves interpreting and understanding novel situations and problems against a background of specific domain knowledge (eg, integrating the presenting complaint, medical history, physical examination and laboratory findings).
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1–5 In fact, little is known about the ED adverse events/errors.Ĭroskerry has stated that cognitive errors underlie most diagnostic errors that are made in the course of clinical decision making in the ED.
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5 However, few studies have measured the risk of adverse events occurring after the discharge of hospitalised medical patients. 4, 5 The ED has been identified as a hot spot where adverse events are more likely to be attributable to error. 2–12 Approximately one half of all adverse events are potentially preventable. 1–3 Several studies have shown that there is a risk of occurrence of an ‘adverse event’, defined as an injury due to treatment, ranging between 2.5% and 11% of all hospitalisations. Due to various extrinsic factors, the emergency department (ED) is one of the most common sites within the hospital for development of adverse events. Patient safety and medical errors are currently major controversial issues.