A 45-year-old female had gone to
ED triage and reported feeling
chest discomfort since 1 hr. She
developed cardiac arrest 15 minutes
after her arrival in the waiting
The purpose of ED triaging is to
quickly assess and categorize
incoming patients and to identify
emergent patients. Patients who are
4. TEAM MEMBERS ARE
FROM A&E DEP.
Healthcare risk is the
chance of an adverse
or patient care.
National Patient Safety Agency 2007,NHS
This is the activities/measures
taken by health care authority
to prevent or mitigate the
occurrence or reoccurrence of a
real or potential (patient)
(WHO, World Alliance for
Patient Safety 2009)
7. Identify, assess &manage the risk in order to
ensure the safety of both patient and staff.
Facilitate, promote and/or ensure appropriate
implementation of risk management in day-to-day
Reorganize systems and policies designed to
optimize risk management in the hospital setting.
One effective way of identification
of potential risk is to follow the
patient's trail. From triage
registration, waiting hall, clinical
encounter, investigation, treatment ,
documentation and disposal.
12. • Action slip or failure (e.g.
picking up the wrong medicine,
• Cognitive failure (e.g. ignorance
or misinterpreting a situation)
• Violations (deviations from safe
medication practices, procedures
or protocols) and breakdown in
documentation communication and
• LATENT FAILURE
• Fallible decisions made by
• Examples are:-
• Heavy work load
• Inadequate knowledge and
• Stressful environment, rapid
13. 1.Inaccurate triage categorization.
2. Prolonged waiting time
3. Failure in resuscitation management.
4. Failure in communications among caregivers &
5. Accidental fall.
6. Improper pain management
7.Shortage of health care workers.
8.Failure in documentation.
9.Failure in following standard protocol.
10.Not seeking help when necessary.
14. Assign an extensive knowledgeable
triage nurse .
Triage nurse should re asses the
waiting patients timely.
He/she should have adequate training
,competent skills and language.
Should be critical thinker &decision
If any doubt chose the
higher acuity to avoid
15. Successful management of polytrauma depends on
the immediate diagnosis and management of the
most life-threatening injuries.
The systematic approach to a critically ill patient by
a team competent group of nurses and physicians
preserves a team’s focus and prevents errors
Authority should arrange mandatory courses for
all A&E staff to improve the professional
knowledge . So that all staff will be competent in
managing any emergency situation without any
failure in patients care.
16. Medication errors are a serious public
health threat, causing patient injury
and death and sharply increasing health
Staff should aware about high-alert
medications which are known to cause
severe injury to patients when
Minimize verbal orders and require that
medication orders to be entered electronically.
Design smooth workflow within the ED in a manner
that improves communication, minimize
interruptions and provides for double checks and
verbal confirmations before medications are given
to the patient.
18. If care is not documented assume it was
not rendered. Nurses’ notes are
recognized as documentary evidence.
IT SHOULD BE:
19. Ineffective communication is the most
frequently cited category of root causes of
Effective communications can:
Improve patient safety.
Improve quality of care .
Decrease length of patient stay.
Improve patient and family satisfaction.
Enhance staff morale and job satisfaction
21. Creation of a standing Risk Committee can
provide focus on risk as an important part of
emergency dep. also can encourage discussions of
ongoing risk reduction tools and programs.
QI programs help avert risk through the
processes of collecting data, performing chart
reviews, promoting appropriate documentation in a
peer-to peer-format and improving the quality of
22. Preventable trauma deaths should be reviewed in trauma
Protocols, policies & procedures should be regularly reviewed
Routine reporting of incidents should be performed as a daily
activity and special rewards should be given to nursing staff
who report incidents, to motivate them towards incident
reporting as a means of risk identification and prevention
rather than punishment.
Diplomatic and careful handling will pay great dividends.
24. Reducing risk and ensuring safety require greater
attention to systems that help to prevent and
In order to improve the skills &knowledge authority
should arrange in-service courses &work shops.
Risk management and quality improvement efforts in
healthcare organizations are rallying behind patient
safety and finding ways to work together more
effectively and efficiently to ensure that their
organizations deliver safe and high-quality patient
While RM & QI department may separately address matters
related to the event, they can also share responsibilities.
The risk manager will assist with the disclosure of the event
to the patient and family . Both quality improvement and risk
management may be involved in conducting a root-cause
analysis of the event and preparing an action plan for
preventing similar events.