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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



Delays in treatment

While hospital Emergency Departments (EDs) are the source of just over one-half of all reported sentinel event cases of patient death or permanent injury due to delays in treatment, Joint Commission sentinel event data reveal that such serious problems can occur in any hospital unit, as well as in other health care settings. Of the 55 reported cases of delays in treatment, 29 were ED-related, while 26 cases originated in hospital intensive care units, medical-surgical units, inpatient psychiatric hospitals, freestanding and hospital-based ambulatory care services, the operating room and in the home care setting.
Of the 55 cases of delays in treatment, 52 resulted in patient death.

The reported reasons for the delays in treatment are many and varied with the most common factor being misdiagnosis (42 percent). Other delaying factors include: delayed test results (15 percent); physician availability (13 percent); delayed administration of ordered care (13 percent); incomplete treatment (11 percent); delayed initial assessment (7 percent); patient left unattended (4 percent); paging system malfunction (2 percent); and unable to locate ER entrance (2 percent).

Of the 23 cases involving misdiagnoses, the most frequent misdiagnosis was meningitis (7); six of the seven cases were in children. Other misdiagnosed conditions included various forms of cardiac disease, pulmonary embolism, trauma, asthma, neurologic disorder, and four cases of unknown diagnosis due to the patient leaving without being evaluated. Of the five cases that occurred in inpatient psychiatric hospitals, all were related to the delayed diagnosis or treatment of non-behavioral medical conditions.


Multiple root causes identified
Analyses of the cases reveal that multiple root causes contributed to each sentinel event, with

Sentinel Event Aler
t Advisory Group

Henri R. Manasse, Jr., Ph.D., Sc.D., Chairman
James P. Bagian, M.D., P.E.
Jim Battles, Ph.D.
William H. Beeson, M.D.
Patrick J. Brennan, M.D.
Sean Clarke, R.N., Ph.D., CRNP
Michael Cohen, R.Ph., M.S., D.Sc.
Jim Conway
Martin H. Diamond, CHE
Cindy Dougherty, R.N., CPHQ
Steven S. Fountain, M.D.
Karl B. Gills, FACHE
Peter Gross, M.D.
Jennifer Jackson, B.S.N., J.D.
Brent James, M.D.
Jane McCaffrey, MHSA, DFASHRM
Mark W. Milner, R.N.
Jeanine Arden Ornt, Esq.
Grena Porto, R.N., M.S., ARM, CPHRM
Carl A. Sirio, M.D.
Ronni P. Solomon, J.D.
Bonnie J. Atterbury Taylor, M.D.
H. G. Whittington, M.D. 


most organizations (84 percent) citing a breakdown in communication, most often with or between physicians (67 percent). Organizations also cited problems with patient assessment process (75 percent); continuum of care issues (62 percent), most often relating to discontinuity of care across settings or shifts; orientation and training of staff (46 percent); availability of critical patient information (42 percent); staffing levels (25 percent); and availability of physician specialists (16 percent). 

Among the ED cases, the most commonly cited root causes were staffing (34 percent) and availability of physician specialists (21 percent); overcrowding was cited as a contributing factor in 31 percent of the cases.

According to an April 2002 American Hospital Association survey of hospitals1, the majority of hospital EDs perceive they are at or over operating capacity with more than 90 percent of large hospitals (300 plus beds) reporting EDs at or over capacity. And, according to the survey, capacity constraints translate into longer waiting times for treatment, longer stays in the ED, and longer waiting times to get admitted to a general acute, critical care, or psychiatric bed. 

"Delays have always been a source of concern for Emergency Departments, due in part to the inability to turn people away," says Michael T. Rapp, M.D., FACEP, past president of the American College of Emergency Physicians, and member of JCAHO's Hospital Professional and Technical Advisory Committee.


"Providing timely treatment and avoiding delays is a constant challenge. Causes of delays tend to be multi-factorial, and both external and internal to the emergency department. Currently, issues of overcrowding are a threat to emergency departments everywhere, frequently stemming from insufficient inpatient beds. Other external factors can include slow turnaround of lab and X-ray results. Within the emergency department itself, there are a number of things that can be done to address delays, including simplifying and standardizing processes, and developing staffing standards that relate to peaks of activity, not averages. It is also important to teach principles of teamwork which can both improve efficiency and enhance patient safety. Among them are communication techniques such as confirming verbal orders."

Risk reduction strategies implemented
As a result of the sentinel events arising from delays in treatment and in response to the many identified root causes, health care organizations implemented multiple and varied risk reduction strategies. These strategies include a redesign of:

  • Orientation and training processes (80 percent)
  • Transfer procedures (27 percent)
  • Staffing plans (25 percent)
  • On-call specialist contact procedures (22 percent)
  • Triage procedures (16 percent)
  • Physical space (11 percent)

Other strategies include the implementation of formal oral communication procedures (25 percent); revised specialist on-call procedures (13 percent); and the revision or redesign of various other procedures such as initial assessment processes, patient information retrieval processes, credentialing and privileging processes, communication of abnormal lab or radiology results, and the implementation of voice recognition transcription software.

To help address communication issues, health care organizations can look to health information management (HIM) professionals who can advise on proper methods of documenting information, and assist in the development of lists of approved or prohibited abbreviations, optimizing information availability, duplicate record control, and addressing issues of timeliness and the completeness of records. "When health information availability issues are identified—whether oral, written or electronic—organizations are encouraged to include HIM professionals into the redesign processes to address problems at the source," says Beth Hjort, R.H.I.A., professional practice manager, American Health Information Management Association (AHIMA). "It is absolutely critical to create an environment and culture where individuals feel safe in asking questions and probing until there is complete understanding."

Joint Commission recommendations
In light of the number of organizations experiencing delays in treatment that cite problems with communication, JCAHO recommends that organizations: 

  1. Implement processes and procedures designed to improve the timeliness, completeness, and accuracy of staff-to-staff communication, including communication with and between resident and attending physicians.
  2. Implement face-to-face interdisciplinary change-of-shift debriefings.
  3. Take steps to reduce reliance on verbal orders and require a procedure of "read back" or verification when verbal orders are necessary. 

In addition, JCAHO recommends 4) that hospital EDs implement strategies to maintain a high index of suspicion for meningitis.

1 Emergency Department Overload: A Growing Crisis. The Results of the American Hospital Association Survey of Emergency Department (ED) and Hospital Capacity, April 2002.