Managing harm in the emergency department. St Emlyn’s

Estimated reading time: 4 minutes

Over the years we have talked a lot about risk on the St Emlyn’s blog and podcast. We might even argue that we have a little expertise in the area. I’m really proud of the team that we have, for the original research we do in areas such as thromboembolic and cardiac risk stratification, in the interpretation of risk and the communication of risk and as a concept in emergency care. Understanding risk is a core skill in emergency medicine and the very best emergency clinicians manage it well. However, in recent times I’ve started to ask myself whether it’s risk that we are truly managing.

Risk is commonly defined as meaning that ‘something’ has the possibility of happening and that the ‘something’ will be negative or dangerous (or more succinctly – harmul). The key concept here is that there is a ‘possibility’ of harm occurring and that’s how we use the concept of risk to stratify patients in the ED and also to talk to patients and colleagues about the potential benefits and risks of drugs/procedures.

As an emergency clinician in modern times we often talk about managing many other risks. Many of these are related to issues of capacity and crowding. For a myriad of reasons emergency departments around the world are trying to cope with many issues such as increasing numbers of patients, patient complexity, staff shortages and most importantly crowding. We often talk about managing the risk associated with this, but is it really ‘risk’ that we are managing?

Whilst many factors contribute to emergency department complexity, there is increasing evidence that crowding is a significant factor in patient outcome. There is less evidence on the effect on staff, but common sense and the recent anecdotal reports of an exodus of many staff from emergency care settings would suggest that the effect is similar amongst colleagues. Our recent blog on the GIRFT data on emergency care outcomes suggested a significant increase in mortality in patients who have delayed stays in the emergency department. The headline figure of one additional death for every 82 patients delayed by 6-8 hours in the ED is shocking. In a department such as Virchester that means that there are additional and potentially unnecessary deaths happening all the time.

So are we really managing a risk? A risk would suggest that there is a possibility of harm, but that’s not what the data tells us. The data tells us that harm is happening, and frequently. The difficulty in understanding this is that attributing the increased harm to an individual patient is often impossible. As a thought experiment try the exercise in the box below.

Exercise 1. You are the clinical governance lead for your emergency department. Your department averages 41 medical admissions a day. The lead pharmacist contacts you tell you that on average there is one fatal drug error every other day in your department. They have the notes of all the patients and the members of staff involved. This has been getting steadily worse for the last 6 months. What would you do? Who would be knocking at your door to resolve this.

Exercise 2. You are the clinical governance lead for your emergency department. Your department averages 41 medical admissions a day. You receive a national report that states that on average 1:82 patients waiting over 6 hours for a bed die unnecessarily. This has been getting steadily worse over the last 6 months What would you do? Who would be knocking at your door to resolve this.

Both these scenarios result in the same number of deaths, but it is clear which one would precipitate immediate action. There are many reasons why, but one of them is the fact that crowding affects population health whereas medical error is usually attributable to an individual(s). Which one would be placed on a risk register and which would require action?

My argument is that when we talk about systems issues such as crowding, defining the problem as a ‘risk’ hides the fact that we know it is really ‘harm’. Perhaps it is time for us talk less about risk management with respect to crowding and much more about harm management and harm minimisation strategies. Perhaps we need a harm register as well as a risk register for our departments? As emergency clinicians you almost certainly know this already, but others do not and using plain language may help them understand.

The bottom line is that harm and risk are different. We should not accept harms as risks and wherever possible make it clear that when harm occurs we carefully, consistently and with great clarity of communication highlight it.



NB. An alternative title for this blog was ‘Why I’m no longer talking to non-ED teams about the risk of crowding in the ED’ . The astute amongst you will recognise that this was inspired by the excellent book ‘Why I’m no longer talking to white people about race’ by Renni Eddo-Lodge. That’s a really interesting book and well worth a read.

Thanks so much for following. Viva la #FOAMed

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