This survey of emergency department physicians found that significant confusion in understanding of Physician Orders for Life-Sustaining Treatment (POLST) documents exists. The authors suggest that additional research and training are required to protect patients' decisions. A related study revealed variation in interpretations of POLST orders by prehospital emergency responders. A previous AHRQ WebM&M commentary discusses how confusion in resuscitation status can result in a patient receiving unwanted care.
Meisel ZF, Shea JA, Peacock NJ, et al. Ann Emerg Med. 2015;65:310-317.e1.
This focus group study with emergency medical services personnel identified several potential ways to improve the quality of handoffs between paramedics and emergency department staff. A structured handoff tool has been developed to address this known safety hazard.
Dawson S, King L, Grantham H. Emergency Medicine Australasia. 2015;25.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.
Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-33.
Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.
Lifshitz AE, Goldstein LH, Sharist M, et al. Am J Emerg Med. 2012;30:726-31.
This study discovered that medication errors were more common in the emergency department setting than in emergency vehicles, and patients requiring multiple medications were at higher risk for medication errors.
Bost N, Crilly J, Wallis M, et al. Int Emerg Nurs. 2010;18:210-20.
This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.
Gustafsson M, Wennerholm S, Fridlund B. Intensive Crit Care Nurs. 2010;26:138-45.
Few studies have addressed patient safety issues during inter-hospital patient transport. This Swedish study used critical incident debriefing techniques to explore factors leading to potential safety problems during transport, based on the perceptions of experienced transport nurses.
After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times.
Lankshear A, Lowson K, Harden J, et al. J Adv Nurs. 2008;63.
This study demonstrated that simply designing "system" safeguards fails to prevent errors in subsequent monitoring and implementation. Investigators used three safety alerts, including latex allergy, as markers of how well these alerts were being adopted in practice by bedside nurses.
Gillman L, Leslie G, Williams T, et al. Emerg Med J. 2006;23:858-61.
This study evaluated nearly 300 adverse events that occurred during intrahospital transport, noting that equipment problems and hypothermia were the most common. Investigators combined 6 months of prospective observation with retrospective chart review to characterize the type and nature of events recorded for patients admitted to the intensive care unit from the emergency department. While the overall rates were lower than reported in past research, the authors advocate for using their findings as benchmarks: an adverse event rate of 22 of 100 transfers and 38 of 100 delays in transfer. A case commentary on Agency for Healthcare Research and Quality (AHRQ) WebM&M discusses the issue of intrahospital transport with suggestions for improving the safety of this poorly studied process.
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