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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
Multiple root causes identified
Analyses of the cases reveal that multiple root causes contributed to
each sentinel event, with
Sentinel Event Alert 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.
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
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
"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
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:
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
Implement processes and procedures designed to improve the
timeliness, completeness, and accuracy of staff-to-staff
communication, including communication with and between resident and