Physicians’ and nurses’ perceptions of patient safety risks in the emergency department

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Highlights

  • The results reflect a complex system with several perceived patient safety risks.

  • High workload was thought to further jeopardize patient safety.

  • RNs expressed that several perceived risks could result in medication errors.

Abstract

The emergency department has been described as a high-risk area for errors. It is also known that working conditions such as a high workload and shortage off staff in the healthcare field are common factors that negatively affect patient safety. A limited amount of research has been conducted with regard to patient safety in Swedish emergency departments. Additionally, there is a lack of knowledge about clinicians’ perceptions of patient safety risks. Therefore, the purpose of this study was to describe emergency department clinicians’ experiences with regard to patient safety risks.

Method

Semi-structured interviews were conducted with 10 physicians and 10 registered nurses from two emergency departments. Interviews were analysed by inductive content analysis.

Results

The experiences reflect the complexities involved in the daily operation of a professional practice, and the perception of risks due to a high workload, lack of control, communication and organizational failures.

Conclusion

The results reflect a complex system in which high workload was perceived as a risk for patient safety and that, in a combination with other risks, was thought to further jeopardize patient safety. Emergency department staff should be involved in the development of patient safety procedures in order to increase knowledge regarding risk factors as well as identify strategies which can facilitate the maintenance of patient safety during periods in which the workload is high.

Introduction

The emergency department (ED) has been described as a high-risk area where errors commonly occur [5], [13], [14]. An error is defined as a failure made in the process of care that results in, or has the potential to result in harm to patients [24]. Working conditions in the ED such as a high workload and staff shortages have been identified in surveys and interviews with ED staff members as common stressors and described as important patient safety concerns [11], [36]. In addition, inadequate equipment, inexperienced staff [19], [38], [42], overcrowding and interruptions [6], [9], [26], [29], [43] have been reported to affect staff performance which has the potential to result in harm to patients. The Swedish National Board of Health and Welfare has reported that high workload and long waiting times for triage and medical assessment constitute risks for errors in ED care [41].

Working conditions affect humans and their behavior [45], and from a patient safety perspective, it is important to identify conditions that affect a clinicians’ work performance and which may contribute to errors. Studies from the healthcare context have shown that working conditions such as a high workload and shortage of staff are associated with compromised patient safety [16] including mortality [1]. Furthermore, negative conditions may affect the performance of registered nurses’ (RN). Conditions, such as insufficient staffing and resources, were strongly related to RNs reporting their perceptions of poor patient safety [37]. However, patient safety risks in the ED may differ from risks in other settings because of the uncontrolled and unpredictable workload.

To conclude, studies from the healthcare context and the EDs have shown that working conditions such as a high workload and staff shortages, among other conditions, affect staff performance and might result in harm to patients. However, there is limited research regarding patient safety in Swedish EDs, and there is a lack of knowledge regarding physicians and RNs perceptions of patient safety risks. Therefore, the purpose of this study was to describe emergency department physicians and RNs perceptions of patient safety risks.

Section snippets

Design

In this qualitative study, individual interviews were used to elicit physicians and RNs perceptions of patient safety risks in an ED context [33].

Study setting and sample

The study was conducted in 2012 at two Swedish EDs for adults including a large urban university hospital with about 82,000 annual visits and a medium-size county hospital with about 58,000 annual visits. In Sweden, EDs are organised based on different medical specialties (e.g., internal medicine, surgery and orthopaedics). The physicians in the ED

Results

Physicians’ and RNs perceptions of patient safety risks are divided into four categories: high workload, lack of control, communication failures, and organizational failures (Table 2). The perceived risks reflect a complex professional practice involved in the daily activities. Each identified subcategory was perceived as a patient safety risk, and often combinations of risks were perceived to further jeopardize patient safety. The RNs expressed that several perceived risks in combination could

High workload

High patient load and work task prioritizing, defined as having to simultaneously prioritize between two critically ill patients, represents the high workload category. High patient load was perceived as a risk and could result in excessive wait times which could significantly delay assessment. Furthermore, a high patient load could result in the medical staff failing to detect a patient’s deteriorating patient condition.

One of the participating physicians said: ‘patients with high triage

Lack of control

The category titled lack of control includes multitasking, interruptions and inexperience. Multitasking in this study refers to managing several tasks at the same time, exemplified by a physician in the following quote: ‘I don’t think we are made to manage seven tasks at the same time, two or three are probably possible to handle’ (p3).

Interruptions were expressed by both physicians and RNs as a risk that affected work performance. They stated that interruptions at times of a high patient load,

Communication failures

Both physicians and RNs considered failures in communication, such as a lack of information and communication flaws, as risks for patient safety. The lack of information regarding incoming transfer patients from other hospitals was viewed as a situation that could jeopardize patient safety. This was expressed by a RN as: ‘receiving no information about an incoming patient can lead to long waiting times and the wrong level of care for the patient’ (n14).

The respondents had the perception that

Organizational failures

Unclear organizational responsibilities, lack of inpatient beds, insufficient staff levels and electronic health record (EHR) flaws represent perceived organizational failures.

Unclear organizational responsibility was described as a patient safety risk that could cause uncertainty about who had the responsibility for patients, may result in a delay before the patient receives care or is admitted. One quote by a physician exemplifies this situation: ‘lack of cooperation when transferring

Discussion

The findings of this study contribute with knowledge regarding risks to patient safety in the ED context as reported by both physicians and RNs, which has previously been scarcely reported in the literature. Patient safety risks were perceived by both professions as multifactorial and involved situations related to a high workload, lack of control, communication and organizational failures. The combination of several perceived risks were thought to further jeopardize patient safety, as for

Methodological considerations

The first author was working in one of the participating EDs, consequently there is a risk that the preunderstanding influenced the interpretation of the data. On the other hand, a combination of experience from everyday work and research gives perspective from two directions that can be an advantage, contributing to a deeper knowledge of the subject of the study.

The interviews were conducted by telephone by two professional interviewers with limited experience or familiarity with the ED

Conclusions

The results reflect a complex system in which a high work load, lack of control, communication and organizational failures was perceived as a risk for patient safety. A high workload, in combination with other risks, was thought to further jeopardize patient safety. The relationship between these risk factors in the ED are largely unknown and need to be explored in future research. Emergency department staff should be involved in efforts to increase patient safety and knowledge about risk

Conflict of interest

There are no conflicts of interest.

This study was funded by Centre for Clinical Research, Dalarna (Grant No. CKFUU-337771).

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