Use of Physician Concerns and Patient Complaints as Quality Assurance Markers in Emergency Medicine.

ABSTRACT Background: The value of systematic evaluation of both patient and physician identified QA issues in emergency medicine remains poorly characterized as a marker for Emergency Department (ED) quality assurance. Objective: The objective of this study was to determine whether systematic screening and evaluation of patient and physician concerns is useful for identifying physician errors resulting in either an adverse event or a near miss event. Methods: Retrospective, observational cohort study of consecutive patients presenting to an urban, tertiary care academic medical center ED with an annual volume of 57,000 patients between January 2008 and December 2014. Our hospital has an electronic system that easily allows physicians to register a concern or self-identify a potential QA issue for subsequent review. In our system, both patient and physician concerns are then assigned for review by physician evaluators not involved with the patients’ care. Patient complaints were initially prescreened by an experienced evaluator and those not pertaining to possible physician error, such as complaints related to billing, creature comfort, communication, nursing related complaints and waiting times were eliminated unless the reviewer identified a possible physician error. If in addition to these other factors, a potential QA issue was present, the case was referred to the QA committee Reviewers are prompted to use a structured 8-point Likert scale to assess for the presence of error and adverse events. If a reviewer assessed that the case involved a possible error or adverse event that resulted in the need for intervention, additional treatment, or caused patient harm, it was referred to a 20-member quality assurance (QA) committee of ED physicians and nurses who made a final determination as to whether or not an error or adverse event occurred. Results: We identified 570 concerns within a data-base of 383,419 ED presentations, of which 33 were patient-generated and 537 were physician-generated. In the subset of cases where there was a complaint by either patient or physician, physician errors that led to a preventable adverse event were detected in 2.9% of cases (95%CI 1.52% to 4.28%). Further analysis revealed that 9.1% (95%CI 2-24%) of patient complaints correlated to preventable errors leading to an adverse event. In contrast, 2.6% (2-4%) of QA concerns made by a physician alone were found to be preventable physician errors leading to an adverse event. Near miss events (errors without adverse outcome) were more accurately reported by physicians, with physician error found in 12.1% of reported cases (95%CI 10-15%) and in 9.1% of those reported by patients (95%CI 2-24%). Adverse events in general that were not deemed to be due to preventable physician error were found in 12.1% of patient complaints (95%CI 3-28%) and in 5.8% of physician QA concerns (95%CI 4-8%). Conclusion: Screening and systemized evaluation of emergency department patient and physician complaints may be an underutilized and efficient quality assurance tool. Patient complaints may more accurately identify physician errors that result in preventable adverse events, while physician QA concerns may be more likely to uncover a near miss that did not lead to an adverse event.