What’s New in the Patient Safety World


October 2009      Unintended Events in the ED


A study from the Netherlands (Smits et al 2009) looked at the occurrence of unintended events in 10 emergency departments and performed root cause analyses to identify many of the causes. Not surprisingly, problems in communication were major causes identified and these especially pertained to collaboration with departments outside the ED.


Of factors internal to the ED, human ones predominate. This would include things like failure to record when a medication was administered or failure to plug the battery of a medical device into an outlet. But organizational errors were also common (eg. incomplete protocols, failure to replace outdated medical equipment, etc.).


But factors external to the ED were especially important, whether they were human factors or organizational ones. These often involved the laboratory or radiology or consultants from medical specialty services or surgical services.


Some limitations of this study may have been a bias toward reporting of less serious unintended events and the fact that most events were reported by nursing rather than medical staff.


The key lesson from this study is that emergency departments need to focus on their communications and collaboration with other departments (especially radiology and the laboratory) and with those services frequently consulting on emergency department patients, such as medical specialists. The authors stress the importance of joint efforts between the emergency department and the outside departments to identify the causes and potential solutions.





Smits M, Groenewegen PP, Timmermans DRM, van der Wal G, Wagner C. The nature and causes of unintended events reported at ten emergency departments. BMC Emergency Medicine 2009, 9: 16











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