EMER Emergency Medicine Events Register “Learning from our errors”

1. EMEREmergency Medicine Events Register“Learning from our errors” Dr Carmel Crock and Ms Anita Deakin “Patient Experience Week” 28-29th April, 2016 Perth, Australia

2. Emergency Medicine Events Register - 2015 London film presentation - Learning from our errors

3. High Risk/Reliability Organizations and Industries

4. Human Error: Models and Management “Perhaps the most important distinguishing feature of high reliability organisations is their collective preoccupation with the possibility of failure. They expect errors and train their workforce to recognise and recover from them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel ones…Instead of making local repairs, they look for system reforms.” Reason BMJ March 2000

5. What is EMER? Specialty-specific incident monitoring What happens in EDs? Why? What can we do to prevent these incidents?

6. Why do things go wrong in an ED? Is it our environment? Is it our training? Is it about how we communicate?

7. Benefits of EMER Raise awareness about error and safety Create a culture where it is safe to discuss error/near misses Honesty, openness Question how we do things How could I/we have done better?

8. EMER as a ‘debrief‘ tool Forgive ourselves after an error Pick ourselves up Error and shame –stress/depression Effect of an error on whole department

9. Rory Staunton

10. Quality = ...... Learning from our error Communication – both between healthcare providers/ with patient Discharge instructions Results checking Partnering with patients for quality in EDs Healthy workplace/ Mentoring juniors

12. Consumer Reporting “Complaints from patients and/or their carers are important indicators of problems in a healthcare system.The patient perspective is important because users of health services may have a different view of problems to those reported by health professionals in the adverse incident reporting systems that are now routine practice in many countries.”[1] “Integrating patients’ perspective broadens the existing understanding of adverse events…..”[1] “Of note, while concerns generated by patients and families most often did not lead to PSI (patient safety incident) identification, we feel strongly that their feedback is still highly valuable for understanding and improving the patient experience” [2] 1. Lang, S., Garrido, M.V., and Heintze, C. (2016) Patients’ views of adverse events in primary and ambulatory care: a systematic review to assess methods and the content of what patients consider to be adverse events. BMC Family Practice. 17:6 2. Reznek, M.A., Kotkowski, K.A., Arce, M.W., Jepson, Z.k., Bird, S.B., and Darling, C.E. (2015) Patient safety incident capture resulting from incident reports: a comparative observational analysis. BMC Emergency Medicine. 15:6

13. EMER - Consumer Reporting • Launched in 2016 • Supported by ACEM and APSF • First emergency medicine specific consumer reporting portal in Australasia • Analysed by expert data analysts and reviewed by people directly involved in emergency medicine (ED directors and physicians, ACEM, consumer advocates) • Enables problems to be reviewed across all hospitals and preventative strategies to be implemented accordingly

14. Consumer Reporting – Why report? • Anonymous, online, secure reporting system • Easy to use • Only takes 5-10 minutes to enter an incident • Information fed back directly to the specialty • Protected under Qualified Privilege • Incidents are reviewed from the consumers perspective!

15. What can I report? • Care that didn’t go as expected or planned (e.g. Incorrect treatment/procedure performed etc) • Care that went better than expected or planned (e.g. Staff member going above the “call of duty”) • Anything that nearly went wrong – “near miss”. (e.g. nurse nearly administered the incorrect medication)

16. Examples of reported incidents Patient bought a live snake in a plastic bag into ED Miscommunication between treating teams during patient inter-hospital transfer

17. What happens with my report?

18. Incident submitted

19. Incident de-identified and classified

20. Data analysed

21. Dissemination of learnings Schultz, T. J., Crock, C., Hansen, K., Deakin, A., & Gosbell, A. (2014). Piloting an online incident reporting system in Australasian emergency medicine. Emergency Medicine Australasia : EMA, 26(5), 461–7. Jones, D. N., & Crock, C. (2009). Parallel diagnostic universes : One patient. How radiologists and emergency physicians share diagnostic error. Journal of Medical Imaging and Radiation Oncology, 53, 143–151. Deakin, A., Schultz, TJ., Hansen, K., & Crock, C. (2014). Diagnostic error: Missed fractures in emergency medicine. Emergency Medicine Australasia : EMA. Deakin, A., & Hansen, K. (2015). Why did you leave us when we wanted you to stay? Emergency Medicine Australasia. 27(5). 488–489 Thomas, M. J., Schultz, T. J., Hannaford, N., & Runciman, W. B. (2012). Failures in Transition: Learning from Incidents Relating to Clinical Handover in Acute Care. J Healthc Qual, Jan 23.

23. Where can I find “EMER”? http://www.emer.org.au/

24. EMER Contacts Via the website Direct email • emer@acem.org.au • Anita.Deakin@unisa.edu.au

25. “Please see me”