Publications

 About EMER

Deakin, A., Schultz, T. & Runciman, B. (2017) Emergency Medicine Events Register (EMER) - Final Report. Adelaide: Australian Patient Safety Foundation EMER_Report_January_2017_Final.pdf

Hansen, K., Schultz, T., Crock, C., Deakin, A., Runciman, W. and Gosbell, A. (2016) The Emergency Medicine Events Register: An analysis of the first 150 incidents entered into a novel, online incident reporting registry. Emergency Medicine Australasia. DOI: 10.1111/1742-6723.12620.  http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12620/full

West, A. (2016) Letter to the editor: One register to rule them all: Emergency Medicine Events register?  Emergency Medicine Australasia. doi: 10.1111/1742-6723.12692. https://www.ncbi.nlm.nih.gov/pubmed/27748015

Crock, C. and Deakin, A. (2016).  Interviewed by Lucy Palermo for Health Matters. EMER: How consumers & clinicians can improve patient experiences in Hospital Emergency Departments. Health Consumers Council (WA) Inc Magazine. Issue 2. 24-25. http://www.hconc.org.au/emer/

Deakin, A. & Smith, B, (2015). Interhospital transfer: How can we get it right? Emergency Medicine Australasia. 27 (5) 492-493.http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12453/epdf

Deakin, A., & Hansen, K. (2015). Why did you leave us when we wanted you to stay? Emergency Medicine Australasia. 27(5). 488–489.http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12447/epdf

Deakin, A., & Shepherd, M. (2015). Knickers in a twist. Emergency Medicine Australasia. 27,618–619 doi:10.1111/1742-6723.12473.http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12473/epdf

Deakin, A., Schultz, TJ., Hansen, K., & Crock, C. (2014). Diagnostic error: Missed fractures in emergency medicine. Emergency Medicine Australasia : EMA. http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12328/epdf

Schultz, T. J., Crock, C., Hansen, K., Deakin, A., & Gosbell, A. (2014). Piloting an online incident reporting system in Australasian emergency medicine. Emergency Medicine Australasia : EMA, 26(5), 461–7. http://onlinelibrary.wiley.com/enhanced/doi/10.1111/1742-6723.12271/

Schultz, T. J., & Deakin, A. (2013). Emergency Medicine Events Register (EMER) - Final Report. Adelaide: Australian Patient Safety Foundation. 


 Incident reporting studies

Schultz, T.J., Hansen, K. and Crock, C. (2016) Re: Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. http://bmjopen.bmj.com/content/6/1/e009837.abstract/reply#bmjopen_el_9640

Lang, S, Garrido MV, Heintze C. (2016). Patients’ views of adverse events in primary and ambulatory care: a systematic review to assess methods and the content of what patients consider to be adverse events. BMC Family Practice. 17(6). doi:10.1186/s12875-016-0408. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728778/

Reznek, M. A., & Barton, B. A. (2014). Improved incident reporting following the implementation of a standardized emergency department peer review process. International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care / ISQua, 26(3), 278–86. http://intqhc.oxfordjournals.org/content/26/3/278.long

Hohenstein, C., Hempel, D., Schultheis, K., Lotter, O., & Fleischmann, T. (2014). Critical incident reporting in emergency medicine: results of the prehospital reports. Emergency Medicine Journal : EMJ, 31(5), 415–8. http://emj.bmj.com/content/31/5/415.abstract

Jepson, Z. K., Darling, C. E., Kotkowski, K. A., Bird, S. B., Arce, M. W., Volturo, G. A., & Reznek, M. A. (2014). Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process. BMC Emergency Medicine, 14(1), 20. https://bmcemergmed.biomedcentral.com/articles/10.1186/1471-227X-14-20

Mandel, C. J., & Runciman, W. B. (2013). System for reporting and analysing incidents. In L. Lau & K.-H. Ng (Eds.), Radiological Safety and Quality (pp. 203–221). Dordrecht: Springer. http://link.springer.com/chapter/10.1007/978-94-007-7256-4_11#page-2

Hannaford, N., Mandel, C., Crock, C., Buckley, K., Magrabi, F., Ong, M., … Schultz, T. (2013). Learning from incident reports in the Australian medical imaging setting: handover and communication errors. The British Journal of Radiology, 86(1022), 20120336. http://www.birpublications.org/doi/abs/10.1259/bjr.20120336

Parmelli, E., Flodgren, G., Sg, F., Williams, N., Rubin, G., & Mp, E. (2012). Interventions to increase clinical incident reporting in health care. Cochrane Database of Systematic Reviews, (8). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005609.pub2/full

Thomas, M. J., Schultz, T. J., Hannaford, N., & Runciman, W. B. (2012). Failures in Transition: Learning from Incidents Relating to Clinical Handover in Acute Care. J Healthc Qual, Jan 23. http://onlinelibrary.wiley.com/doi/10.1111/j.1945-1474.2011.00189.x/full

Thomas, M. J., Schultz, T. J., Hannaford, N., & Runciman, W. B. (2011). Mapping the limits of safety reporting systems in health care - what lessons can we actually learn? MJA, 194 (12), 635-639. https://www.mja.com.au/journal/2011/194/12/mapping-limits-safety-reporting-systems-health-care-what-lessons-can-we-actually

Brubacher, J. R., Hunte, G. S., Hamilton, L., & Taylor, A. (2011). Barriers to and incentives for safety event reporting in emergency departments. Healthcare Quarterly (Toronto, Ont.), 14(3), 57–65. https://www.ncbi.nlm.nih.gov/pubmed/21841378

Hashemi, K., Khaliq, W., & Blakeley, C. (2010). Patient safety incident reporting in an emergency department: A one-year review. Clinical Risk, 16(1), 3–5. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-75949126119&partnerID=40&md5=0c87a96215dc9e1a41747fb4332ce26a

Vinen, J., & Cosby, K. S. (2009). Incident Monitoring in the Emergency Department. In P. Croskerry, K. S. Cosby, S. M. Schenkel, & R. L. Wears (Eds.), Patient Safety in Emergency Medicine (pp. 75–80). Philadelphia: Lippincott Williams & Wilkins. http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2000.tb00478.x/epdf

Tighe, C. M., Woloshynowych, M., Brown, R., Wears, B., & Vincent, C. (2006). Incident reporting in one UK accident and emergency department. Accident and Emergency Nursing, 14(1), 27–37. http://www.sciencedirect.com/science/article/pii/S0965230205000780

Thomas, M., Morton, R., & Mackway-Jones, K. (2004). Identifying and comparing risks in emergency medicine. Emergency Medicine Journal, 21(4), 469–472. http://emj.bmj.com/content/21/4/469.full

Vinen, J. (2000). Incident Monitoring in Emergency Departments An Australian Model. Academic Emergency Medicine, 7(11), 1290–1297. http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2000.tb00478.x/abstract


 Patient safety in Emergency Medicine

ACEM. (2017). "A new take: Diagnostic errros under the spotlight". https://acem.org.au/News/2017/June/A-new-take.aspx

Okafor, N.G., Doshi, P.B., Miller, S.K., McCarthy, J.J., Hoot, N.R., Darger, B.F., Benitez, R.C. and Chathampally, Y.G. (2015). “Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department”. Western Journal of Emergency Medicine. XVI(7). 1073-1078 DOI: 10.5811/westjem.2015.8.27390. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4703179/

Okafor, N., Payne, V.L., Chathampally, Y., Miller, S., Doshi, P. and Singh, H. (2016) “Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine”. Emergency Medicine Journal. 33:245252.. doi:10.1136/emermed-2014-204604. http://emj.bmj.com/content/early/2015/11/03/emermed-2014-204604.abstract

Hesselink, G., Berben, S., Beune, T., & Schoonhoven, L. (2016). Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 6(1). doi:10.1136/bmjopen-2015-009837 http://bmjopen.bmj.com/content/6/1/e009837.full

Wears, R. L., Woloshynowych, M., Brown, R., & Vincent, C. A. (2010). Reflective analysis of safety research in the hospital accident & emergency departments. Applied Ergonomics, 41(5), 695–700. http://www.sciencedirect.com/science/article/pii/S0003687009001665

Jones, D. N., & Crock, C. (2009). Parallel diagnostic universes : One patient. How radiologists and emergency physicians share diagnostic error. Journal of Medical Imaging and Radiation Oncology, 53, 143–151. http://onlinelibrary.wiley.com/doi/10.1111/j.1754-9485.2009.02052.x/abstract

Smits, M., Groenewegen, P. P., Timmermans, D. R. M., van der Wal, G., & Wagner, C. (2009). The nature and causes of unintended events reported at ten emergency departments. BMC Emergency Medicine, 9, 16. https://bmcemergmed.biomedcentral.com/articles/10.1186/1471-227X-9-16

Friedman, S. M., Provan, D., Moore, S., & Hanneman, K. (2008). Errors, near misses and adverse events in the emergency department: What can patients tell us? Canadian Journal of Emergency Medicine, 10(5), 421–427. https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/errors-near-misses-and-adverse-events-in-the-emergency-department-what-can-patients-tell-us/F445E5E702DDDE377E7E61222ED2B130


Error in Emergency Medicine 

Aaronson EL, Brown D, Benzer T, Natsui S & Mort E. (2017) Incident Reporting in Emergency Medicine: A Thematic Analysis. Journal of Patient Safety. Incident_Reporting_in_Emergency_Medicine_A_Thematic_Analysis_of_Events.pdf

Marco CA, Kowalenko T. Emergency medicine residents’ perspectives on patient safety and duty hours. Am J Emerg Med. 2015/02/11 ed. 2014; http://www.sciencedirect.com/science/article/pii/S0735675714008729

Sherbino, J., Kulasegaram, K., Howey, E., & Norman, G. (2014). Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: a controlled trial. CJEM, 16(1), 34–40. https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/ineffectiveness-of-cognitive-forcing-strategies-to-reduce-biases-in-diagnostic-reasoning-a-controlled-trial/B768948819704516DBE325909A8D611E

Kahllberg, A. S., Goransson, K. E., Ostergren, J., Florin, J., & Ehrenberg, A. (2013). Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients - a national review. European Journal of Emergency Medicine, 20(1), 33–38. http://journals.lww.com/euro-emergencymed/Fulltext/2013/02000/Medical_errors_and_complaints_in_emergency.7.aspx

Friedman, S. M., Sowerby, R. J., Guo, R., & Bandiera, G. (2010). Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey. CJEM., 12(6), 491–9. https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/perceptions-of-emergency-medicine-residents-and-fellows-regarding-competence-adverse-events-and-reporting-to-supervisors-a-national-survey/B9D08D3686418F2C48D536F107C5A7A9

Thomas, M., & Mackway-Jones, K. (2008). Incidence and causes of critical incidents in emergency departments: A comparison and root cause analysis. Emergency Medicine Journal, 25(6), 346–350. https://www.ncbi.nlm.nih.gov/pubmed/18499816

Wears, R. L., & Nemeth, C. P. (2007). Replacing hindsight with insight: toward better understanding of diagnostic failures. Annals of Emergency Medicine, 49(2), 206–9. http://www.sciencedirect.com/science/article/pii/S0196064406021470

Croskerry, P., & Sinclair, D. (2001). Emergency medicine: A practice prone to error. Canadian Journal of Emergency Medicine, 3(4), 271–276. https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/emergency-medicine-a-practice-prone-to-error/5F0A0D7B9B2436AE632EAAD2393CAB3D 


Consumer reporting

Deakin A and Crock C. (2017) “Consumer Reporting of Diagnostic Errors in Emergency Medicine”. AusDEM 2017 poster abstract AusDEM poster abstract

Leistikow, I., Mulder, S., Vesseur, J. and Robben, P. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Quality & Safety. 0:15. doi:10.1136/bmjqs-2015-004853. (2016). http://qualitysafety.bmj.com/content/early/2016/04/01/bmjqs-2015-004853.full

O’Hara, J.K. and Lawton, R.J. At a cross roads? Key challenges and future opportunities for patient involvement in patient safety. BMJ Quality & Safety. doi:10.1136/bmjqs-2016-005476 (2016) http://qualitysafety.bmj.com/content/early/2016/06/28/bmjqs-2016-005476

 

Glickman, S.W., Mehrotra, A., Shea, C.m., Mayer, C., Strckler, J., Pabers, S., Larson, J., Goldstein, B., Mandelkehr, L., Cairns, C.B., Pines, J.M. and Schulman, K.A. A Patient Reported Approach to Identify Medical Errors and Improve Patient Safety in the Emergency Department. Journal of Patient Safety (2016) https://www.ncbi.nlm.nih.gov/pubmed/27811598

 

 


Patient safety and error in other disciplines

Sierzenski PR, Linton OW, Amis ES, et al. Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine. J Am Coll Radiol [Internet]. 2014 Jan [cited 2014 Oct 14];11(1):36–44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135540 

Wolff M, Macias CG, Garcia E, et al. Patient safety training in pediatric emergency medicine: a national survey of program directors. Acad Emerg Med. 2014/08/16 ed. 2014;21(7):835–8. http://onlinelibrary.wiley.com/doi/10.1111/acem.12418/full

Hannaford, N., Mandel, C., Crock, C., Buckley, K., Magrabi, F., Ong, M., Allen, S., Schultz, T. (2013). Learning from incident reports in the Australian medical imaging setting: handover and communication errors. The British Journal of Radiology, 86(1022), 20120336. http://www.birpublications.org/doi/full/10.1259/bjr.20120336

Runciman, W. B., Baker, G. R., Michel, P., Dovey, S., Lilford, R. J., Jensen, N., … Bates, D. (2010). Tracing the foundations of a conceptual framework for a patient safety ontology. Quality & Safety in Health Care, 19(6), e56. http://qualitysafety.bmj.com/content/19/6/e56.long

Runciman, W., Hibbert, P., Thomson, R., Van Der Schaaf, T., Sherman, H., & Lewalle, P. (2009). Towards an International Classification for Patient Safety: key concepts and terms. International Journal for Quality in Health Care, 21(1), 18–26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2638755/

Thomson, R., Lewalle, P., Sherman, H., Hibbert, P., Runciman, W., & Castro, G. (2009). Towards an International Classification for Patient Safety: a Delphi survey. Int J Qual Health Care, 21(1), 9–17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2638754/

Donaldson, L. (2009). An international language for patient safety. International Journal for Quality in Health Care, 21(1), 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2638756/

Sherman, H., Castro, G., Fletcher, M., Hatlie, M., Hibbert, P., Jakob, R., … Virtanen, M. (2009). Towards an International Classification for Patient Safety: The conceptual framework. International Journal for Quality in Health Care, 21(1), 2–8. http://intqhc.oxfordjournals.org/content/21/1/2

Schiff, G. D., Hasan, O., Seijeoung, K., Abrams, R., Cosby, K., Lambert, B. L., … Mcnutt, R. A. (2009). Diagnostic Error in Medicine: Analysis of 583 physician-reported errors. Archives of Internal Medicine, 169(20), 1881–1887. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108559

Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13), 1493–9. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486642

Croskerry, P. (2003). The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Medicine, 78(8), 775 - 780. http://journals.lww.com/academicmedicine/pages/articleviewer.aspx?year=2003&issue=08000&article=00003&type=abstract

Reason, J. (2000). Human error: models and management. BMJ, 320, 768–770. http://www.bmj.com/content/320/7237/768

Mills, A.M., Raja, A., Marin, J.R. (2015) Optimizing Diagnostic Imaging in the EmergencyDepartment. Society for Academic Emergency Medicine. http://onlinelibrary.wiley.com/doi/10.1111/acem.12640/epdf

Kanzaria, H.K., Hoffman, J.R., Probst, M.A., Caloyeras, J.P., Berry,S.H., Brook,R.H. (2015). Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging. Society for Academic Emergency Medicine. http://www.ncbi.nlm.nih.gov/pubmed/25807868


 Presentations

Crock, C and Hansen, K. (2017) "Diagnostic Error in Emergency Medicine - Using a Voluntary, Online Reporting System to Identify Diagnostic Errors in Australasian Emergency Departments". AusDEM. AUSDEM_Diagnostic_error_Presentation.pdf

Deakin, A. (2017) “Consumer Reporting of Diagnostic Errors in Emergency Medicine” (Rapid fire presentation), AusDEM. AUSDEM_Consumer_reporting_Presentation.pdf 

Deakin, A (2017) "Consumer Reporting of Diagnostic Errors in Emergency Medicine” (poster), AusDEM. AusDEM poster

Crock, C. (2016). Houston, we've had a problem. ACEM ASM, New Zealand. Houston, we've had a problem.

Hansen, K (2016). Voices from the grave: Deaths in the emergency services register. ACEM ASM, New Zealand. Voices from the Grave

Crock, C. and Deakin, A. (2016) Patient Experience Week. Health Consumers Council. WA, Australia. HCC Presentation 2016

Hansen, K (2016). Emergency Medicine Events Register: A Clinical analysis of Procedural Errors. The Social Media and Critical Care Conference, Dublin, UK.Poster SMACC

Crock, C (2015). EMER BMJ Video - Learning from our errors. 20th International Quality and Safety Forum in Healthcare. London. View via https://www.youtube.com/playlist?list=PLVdY5G6w32NiIHF4C54LTi5BPwaMSps4O

Hansen, K. (2014a). Emergency Medicine Events Register: a new online portal for incident monitoring. In ICEM. Hong Kong.

Hansen, K. (2014b). e-poster - Emergency Medicine Events Register: a new online portal for incident monitoring. In ACEM Queensland Autumn Symposium. Brisbane.

Hansen, K. (2013a). EMER: Emergency Medicine Events Register, the first 6 months. In ACEM Queensland Autumn Symposium. Brisbane.

Hansen, K. (2013b). Emergency Medicine Events Register (EMER). In Australasian College for Emergency Medicine Annual Scientific Meeting. Adelaide. Retrieved from http://vimeo.com/94130386

Hansen, K. (2012). Emergency Medicine Events Register (EMER). In Australasian College for Emergency Medicine Annual Scientific Meeting. Hobart.

Schultz, T. J., & Magrabi, F. (2012). Specialty specific incident reporting systems in healthcare. In Measuring and Reducing Avoidable Adverse Events. Sydney.

Crock, C. (2010). Development of an Australasian Incident Reporting System for Emergency Medicine. In ACEM Annual Scientific Meeting. Canberra.

Source: Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P: Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care 2009, 21:18-26.

A patient safety incident (an ‘incident’) is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. The use of the term ‘unnecessary’ in this definition recognizes that errors, violations, patient abuse and deliberately unsafe acts occur in healthcare and are unnecessary incidents, whereas certain forms of harm, such as an incision for a laparotomy, are necessary. The former are incidents, whereas the latter is not.

Incidents are classified into a number of different types.