JULY 2014

RISK INSIGHTEmergency Medicine Roundtable

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Risk InsightRisk Insight

Executive summaryVMIA convened an emergency medicine roundtable of senior multidisciplinary emergency department staff, as part of its clinical risk program.

The aim of the roundtable was to identify, analyse and validate the key causes and contributing factors of medical indemnity claims arising from emergency medicine.

Two key discussion inputs were provided: a VMIA commissioned literature review and an analysis of VMIA claims data from the past 10 years.

The literature review revealed that seven leading factors were consistent across multiple studies. Diagnostic error accounted for 55 per cent of claims, while the claims data showed that meningitis and other neurology claims occurred frequently, and at high cost.

The roundtable identifi ed four key areas that would benefi t from focussed attention and program development. The areas are:

• risk identifi cation

• communication

• cognitive strategies

• culture.

Suggested initiatives to consider Roundtable participants also discussed a number of initiatives that could provide an opportunity for VMIA, in partnership with providers, to assist in reducing risk associated with emergency care. The following suggestions arose:

1. Non-technical skills training that provides multidisciplinary teams with an opportunity to refi ne non-technical skills as part ofhighly effective teams. The need for training in principles of teamwork and communication to reduce adverse events andimprove safety culture was emphasised. Non-technical skills can be classifi ed in four broad areas:

• Leadership and management

• Teamwork and cooperation

• Problem-solving and decision-making

• Situational awareness.

2. Supports that provide junior doctors with access to experienced clinicians to facilitate improved clinical decision making.Coupled with this is an opportunity to identify missed clinical problems through the review of high-risk patients.

3. Regarding data management, opportunities exist to regularly monitor and review a variety of data inputs and methods toimprove patient safety. Innovative interventions are required to address the follow up of results, and the issue ofclinical handover.

VMIA will now consider Clinical Risk Management Partnership Projects, via an expression of interest process, to collaborate with health services and key stakeholders to develop and implement targeted risk minimisation initiatives.

IntroductionReducing preventable adverse events in emergency medicineAs part of VMIA’s mission to reduce the total cost of risk to the State, its Medical Indemnity Strategy aims to improve health outcomes for public patients by reducing the frequency, impact and cost of preventable adverse events.

The objectives of the Medical Indemnity Strategy are summarised as follows:

1. Infl uence the reduction in the number and cost of preventable adverse events occurring in public hospitals that lead to claims.

2. Infl uence the reduction in the number and cost of medical negligence claims by improving health care management.

3. Develop a sustainable cost model for medical indemnity insurance for public health services in Victoria by:

• managing litigation fairly and consistently

• optimising the delivery of risk and insurance services

• identifying and promoting strategic risk partnership and initiatives that materially improve patient outcomes.

Each year, around 3500 adverse incidents are reported to VMIA. Of these, around 350 become medical indemnity claims for compensation. These claims vary from small losses through to events involving permanent and severe disability, death, and nervous shock. Emergency medicine claims are diverse by nature and include both low-volume and high-value claims. Examples include delayed diagnoses of bacterial meningitis and high-volume low-value claims such as missed diagnoses of fractures or cut tendons.

Emergency medicine accounts for 16 per cent of all VMIA Medical Indemnity liabilities and is the second highest risk specialty behind maternity care. The specialties of maternity, emergency medicine and general surgery represent 70 per cent of all medical indemnity liabilities.

The VMIA net claims liabilities for medical indemnity claims was $1.04 billion at 30 June 2013, and approximately 70 per cent of claims costs arise from catastrophic claims. Obstetrics, emergency medicine and general surgery represent a small volume of high cost claims. VMIA provides indemnity on a “claims incurred” basis – the date on which the incident occurred.This means that medical indemnity claims can be reported many years after the incident date and may take an average of 10 years to settle. Contributing to these high costs are the high annual costs of care for patients as well as the long term nature of the ongoing care required.

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Emergency medicine roundtableVMIA convened an emergency medicine roundtable of senior multidisciplinary emergency department staff as part of its clinical risk program. The aim was to identify, analyse and validate the key causes and contributing factors of claims arising from the sector. Participants were asked to:

• provide insights around key clinical and system drivers that lead to medical indemnity claims

• distil the causes and contributing factors related to these risks

• identify opportunities for consideration.

VMIA will engage with the public health sector to prioritise issues identifi ed by the round table.

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Risk Insight

The roundtable included the following participants:

• Diana Badcock, ED Director, Bendigo Health.

• Rhonda Beattie Manning, Divisional Director of Emergency, Medicine and Cancer, Western Health.

• Thomas Chan, Director of Casey Emergency and the acting Chair of the Quality Safety Committee for the Emergency Program, Monash.

• Sue Cowling, Nursing Manager, St Vincent’s Emergency Department.

• Julie Considine, Professor of Nursing, Eastern Health (Deakin University).

• Karen Dunn, Paediatric Emergency Physician, Royal Children’s Hospital.

• Manny Geaboc, Divisional Clinical Director Acute Emergency and Intensive Care, Goulburn Valley Health.

• Marie Gerdtz, Associate Professor of Nursing, Melbourne Health and the University of Melbourne.

• Fergus Kerr, ED Director, Austin Health.

• Ben Lui, Emergency Physician, Northern Hospital.

• Andrew Maclean, Director of Emergency, Box Hill Hospital.

• Ron Mann, Senior Mental Health Nurse, Austin Health.

• Jan Pannifex, Manager of the Emergency Care Improvement and Innovation and Clinical Network in the Commission for Hospital Improvement, Department of Health.

• Jeremy Stevens, Emergency Physician and Acting Deputy Director, Emergency, Alfred Hospital.

• Melinda Truesdale, Emergency Physician and Director, The Royal Melbourne Emergency Department.

• Fiona Webster, Executive Director of Acute Operations, Austin Health.

Karen Dunn, Paediatric Emergency

Physician, Royal Children’s Hospital.

Marie Gerdtz, Associate Professor of

Nursing, Melbourne Health and the

University of Melbourne.

Fergus Kerr, ED Director, Austin Health.

Causal factors contributing to emergency medicine claimsAn analysis of VMIA claims data and a literature review revealed the causal factors that contribute to emergency medicine claims.

Literature reviewVMIA commissioned University of Melbourne to conduct a literature review for the roundtable. The review revealed that seven leading causal factors were consistently identifi ed across multiple studies.

Within each of these categories, it is possible to drill down to identify underlying causes. For example, diagnostic errors commonly involve cognitive biases such as fi xation error or a failure to request appropriate tests or consultation. Another category example includes treatment delays, which are commonly attributed to excessive workloads and inadequate staffi ng.

Causal factors Percentage of claims

Diagnostic error 55

Inadequate handovers 24

Failure to adhere to clinical practice or hospital guidelines 17

Lack of appropriate supervision 30

Missed test results 16

Treatment delays 11

Medication errors 6

A review of the literature found that most claims cluster around a small number of high-risk diagnoses. These include myocardial infarction, fractures, wounds, abdominal aortic aneurysms, meningitis, subarachnoid haemorrhage and appendicitis. In the paediatric emergency departments, high-risk diagnoses include testicular torsion, epiglottitis, pneumonia, and neurological impairment of a newborn. A number of claims also arise from either an allegation of a failure to diagnose, often after multiple presentations, or a delay in diagnosis.

Claims analysisVMIA claims data, over the last ten years, indicates that claims for fractures are frequent, although of a low cost. Conversely, meningitis and other neurology claims (missed diagnosis of an incipient stroke or intracranial bleeding) represent high cost claims and are also frequent. Missed diagnoses of aortic aneurysms, ectopic pregnancies, appendicitis, acute coronary syndrome and sepsis were the next most common claims.

VMIA claims data from 2003-2013 (Emergency medicine specialty)

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Emergency medicine roundtable: Summary of issues

Risk identifi cationParticipants discussed whether VMIA’s data provides an accurate indication of the risk profi le of the emergency department situation. The group noted the decision to complain and/or make a claim for compensation may relate more to patient management. That is, how the patient was managed during and after the adverse event rather than the event itself. Patient dissatisfaction is a known driver of claims.1

Agreement was reached that analysis of adverse events should include the patient journey to determine the chain of causation. For example, the root cause might have been an error made by an intern, or a failure to follow a clinical guideline. Similarly, failure to diagnose a clinical condition may be caused by communication issues such as review of X-rays by a radiologist after the patient has left the emergency department. There was general acceptance that an annual analysis of VMIA claims data from various sources will assist in detecting changes and causes. The involvement of Emergency Department Directors and Nurse Unit Managers would add value.

CommunicationFour specifi c areas of communication were identifi ed as requiring attention.

Follow upA major issue raised was the absence of a robust protocol to ensure that pathology and x-ray tests ordered in the emergency department were reviewed and acted upon. Participants spoke of differing procedures for review of test results with no single “best way” identifi ed.

Paediatrics was singled out as an area where communication failure was a major weakness. An example presented was a situation such as failing to give adequate instructions to the parents whose child was being discharged with no specifi c diagnosis having been made. Lack of clear instruction at discharge often results in a complaint. For example, if a fracture is missed and families have no clear indication of what to do, no expectation that there may be something wrong, and are unsure of when to return to the emergency department if symptoms persist or worsen. All staff should be encouraged to use the “Tell Back” or “Read Back” technique when giving instructions to patients and carers, demonstrating that instructions have been received accurately.

HandoverWhile nursing communication during handovers is highly structured at the commencement and end of shifts, medical staff handovers tend to be haphazard. Challenges are posed when the handover involves high numbers of patients, all at different stages of work-up. Handover in other areas usually involves lower patient numbers so information retention is less a risk. Verbal handover with written material would improve information transfer.

The literature recommends the adoption of a standardised handover protocol to reduce miscommunication and promote standard practice across hospitals. Effective handover also helps to maintain continuity of care across shifts, and can provide a fresh perspective on the diagnosis and appropriateness of care. Studies have shown that standardised handovers improve accuracy and completeness, and that structured communication reduces risk.

1 VMIA Data Analysis Report – 2010

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Risk Insight

The emergency medicine roundtable identifi ed four key areas for attention: risk identifi cation, communication, cognitive strategies and culture.

DocumentationThe medical record is central to communication around patient care. The major driver of improvement in the quality of medical records is often a culture in which inadequate and/or illegible records become regarded as unacceptable. Such a culture drives a demand for the provision of better communication and record-keeping tools. These include bedside electronic devices for direct electronic entry into records, and recording equipment to allow dictation of operating case notes, summaries and letters. However, simply providing these tools will not improve record keeping unless there is a demand-driven culture that recognises the importance of good documentation on a medical record.

Supervision of junior doctors

Participants agreed that the practice of launching interns to work solo with indirect supervision after a brief orientation still occurs. For this reason, discussion at the roundtable addressed the broader issue of junior doctors.

Participants highlighted how some hospitals initially schedule interns to work with a consultant. This involves observing the consultant take the history and examine the patient (assisting with the recording in the notes of both), learning how the consultant assesses the patient, providing a differential diagnosis and developing a plan of care with instructions on follow up. Other participants said there are simply not enough consultants in their emergency departments to follow that practice.

Hospitals that initially roster junior staff to work with consultants is the preferred practice by forum participants. This allowed junior staff to see and understand, one-on-one, how a senior decision-maker worked, and the processes involved.

The roundtable highlighted the substantial tension surrounding priorities in the use of consultants. Should they be used mainly to supervise junior staff? Should this time be protected? Or should the time be used to see patients and hence reduce waiting times?

Cognitive strategiesCognitive factors are the leading cause of missed diagnoses. Cognitive strategies provide emergency department clinicians with the skills and knowledge needed to strengthen their logical reasoning and to combat cognitive biases. This helps clinicians to avoid common pitfalls associated with misdiagnoses such as failure to adhere to clinical pathways. Research into the effectiveness of cognitive strategies in reducing diagnostic error is still in its infancy. However, academics in the fi eld claim an urgent need for more research to evaluate the merits of different cognitive interventions and strategies in clinical practice.

Three cognitive strategies were indentifi ed.

Non-technical skills training and simulation-based multidisciplinary teamwork trainingMultidisciplinary simulated training allows emergency department doctors, nurses and allied health providers to learn specifi c clinical and team-based skills using simulators in a safe, supportive learning environment. Simulators enable clinicians to practice responding to high-risk emergency department scenarios as part of a multidisciplinary team, which can improve awareness of common cognitive pitfalls. Early evidence indicates that simulation training is correlated with improved clinician performance and better patient outcomes.

Effective handover also helps to maintain continuity of care across shifts, and can provide a fresh perspective on the diagnosis and appropriateness of care.

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Clinical pathwaysOne roundtable suggestion was to create an emergency department specifi c e-library as a repository of practical clinical pathways and information in a readily accessible format. Access to clinical practice guidelines is available from the United States National Guidelines Clearinghouse, which is modifi ed and adapted to the Australian context,

Studies show that clinical pathways have substantial potential for reducing the risk of misdiagnosis and improving patient reported measures relating to quality of care.

The literature review found that clinical pathways and diagnostic checklists can provide clinicians with a system level and evidence-based approach to responding to particular clinical scenarios. This would assist in overcoming the failure to adhere to clinical guidelines, and could also be used in direct consultation with patients themselves.

It was also mentioned that junior emergency department physicians, to save time, simply used Google on their smartphone to access information on diagnosis and treatment protocols. They did this instead of using a hospital computer to look up the hospital’s specifi c protocols and pathways. This further supports the need for an emergency department specifi c clinical guideline repository.

Also discussed was a state-wide, universally sanctioned database of emergency department protocols and pathways available through an open access website.

Decision-support systems Concern was expressed by participants at the considerable variance in clinical practice in the emergency department community – even by senior staff. There is a fi ne balance between the use of clinical judgment in a particular case and the right of hospitals to insist on hospital-wide observance of promulgated protocols and guidelines.

In conjunction with this, the literature review found that clinical decision-support systems are information systems providing clinicians with assistance in decision-making, which include reminders about treatments and interventions for specifi c patients. It has been suggested that decision-support systems can improve performance in diagnosis, preventative care, disease management and prescribing. However, the cost-effectiveness and impact on patient outcomes is still uncertain. Hospitals report a number of barriers to the implementation of such a start-up and maintenance costs.

There was considerable discussion around limited coverage over weekends, and during afternoon and night shifts. Also mentioned was inadequate tools and approaches to manage surges in patient fl ow in emergency departments, due to the 24-hour nature of the environment.

CultureVMIA’s literature review found that a strong patient safety culture is one in which safe care is promoted through strong leadership, effective accountability, and a culture of openness, honesty and learning. A growing body of evidence suggests that hospitals with good patient engagement have a lower incidence of adverse events and patient harm.

Broad discussion included the impact of culture on the sector and organisations in general. It was felt that many emergency departments already have a non-hierarchical culture based on teamwork. However, mutual respect and openness can be lacking. Adverse events need to be treated as opportunities to learn, not opportunities to apportion blame and punishment. Negative behaviour at any level of seniority was at times still occurring and should not be tolerated, especially bullying. However, some emergency departments have work to do on these aspects as culture takes time to develop and embed across organisations. This is likely a diffi cult area to address, but would make an excellent focus for further discussion.

Concern was expressed by participants at the considerable variance in clinical practice in the emergency department community – even by senior staff.

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Risk Insight

Next stepsThe roundtable determined priorities in three key areas that are worthy of further attention. VMIA will consider Clinical Risk Management Partnership Projects, via an expression of interest process, that demonstrate collaboration with health services and key stakeholders to develop and implement targeted risk minimisation initiatives.

1. Develop non-technical skills trainingConstruct a framework and curriculum to provide multidisciplinary teams with an opportunity to refi ne the non- technical skills of highly effective teams. It is known that effective teamwork plays a major role in alleviating communication problems in high-reliability industries such as aviation, nuclear power and offshore oil production. The need for teaching principles of teamwork and communication to reduce adverse events is essential. Studies in healthcare also show that such training improves safety culture and attitudes across a range of specialty settings. Non-technical skills can be classifi ed in four broad areas:

1. Leadership and management

2. Teamwork and cooperation

3. Problem-solving and decision-making

4. Situational awareness.

The framework would have an overfl ow effect in helping the multidisciplinary team to understand the need for open communication with patients, clear and accurate documentation, and the need to speak up. This would lead to other improvements in care delivery.

2. Improve clinical decision supports• Supervision of junior doctors

Full-time consultant coverage in the emergency department appears to be associated with improved risk management and fewer medical indemnity claims. Junior staff sometimes “don’t know what they don’t know” and may overestimate their own abilities. Adequate, full-time emergency department consultant coverage improves patient access to highly experienced clinicians and can result in closer supervision of trainees.

• Review of high-risk patientsThere is an opportunity to identify missed clinical problems with a review of patients identifi ied as high-risk before discharge, allowing for re-examination. Re-evaluating high-risk patients has been shown to reduce the likelihood of missed diagnoses, or errors in diagnosis. This can subsequently reduce the risk of patients being discharged prematurely or incorrectly. In a study where patients were comprehensively re-evaluated within 24 hours of admission to emergency department with trauma, 14 per cent were identifi ed with a missed injury, such as another fracture.

• Use and development of clinical pathwaysDevelopment of generic clinical pathways and diagnostic checklists can provide emergency department clinicians with a system-level and evidence-based approach to responding to particular clinical scenarios. These can be used in direct consultation with patients themselves.

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ConclusionRegardless of the advances in care, experience, skill and dedication of clinicians, preventable adverse events do occur. This is due to a multitude of factors such as the complexity of patient care, human error, system failure or deviation from evidenced based guidelines.

The roundtable aimed to itemise strategies that can be implemented to prevent adverse events and minimise the associated harm and consequences.

VMIA will consider Clinical Risk Management Partnership Projects, via an expression of interest process, that demonstrate collaboration with other health services and key stakeholders to develop and implement targeted risk minimisation initiatives.

3. Take advantage of data management opportunities• Data analysis

Claims and complaints data cannot accurately refl ect complete clinical risk data. The Department of Health Clinical Governance Framework2 highlights that proactive risk management activities need to be monitored regularly and reviewed annually, using a variety of data inputs and methods to improve patient safety and develop innovative interventions. There was general acceptance among roundtable participants that an annual analysis of the various data collected from multiple organisations to detect changes is required to explore their causes, coupled with continuous involvement of emergency department directors and nurse unit managers to enact changes required.

• Communicating resultsOpportunity exists to explore how Victorian emergency departments are managing the monitoring and communication of results of pathology and imaging tests. In an ideal world, all test results would be reviewed and actioned by the doctor who saw the patient through sophisticated alerts and technology interactions. The forum discussed that there is often not enough time to ensure that the doctor who reviews the result, also reviews, simultaneously, the patient’s notes to identify why the test was ordered. It is recommended that investment is made to leverage the numerous technology solutions that currently exist to address this issue.

2 Quality and Safety in Health Care, April, 2009, Vol.18(2), p.109(7)

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The information provided in this document is intended for general use only. The VMIA does not warrant the information in this document and does not accept any liability to any person for information or advice or the use of such information or advice provided in this document. VMIA encourages the free transfer, copying and printing of this document if such activities support the purpose and intent for which this document was developed. This document is protected by and its use subject to the terms of VMIA’s Copyright Licence.

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