Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.

 Refers to mechanisms or programs designed to review patient care in the emergency department (E.D.) for :
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Identification of errors or deficiencies in patient care
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Training E.D. staff to avoid errors and correct deficiencies
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Overall improvement of quality of care offered
 Also termed "Continuous Quality Improvement"
(CQI) to emphasize the lack of "guarantee" in the process & need for ongoing avtivity

 One or more of these may be useful and applicable for any E.D. :
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Daily review of some or all of the prior day's E.D. patient care records (charts)
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Review and reports on specific "directed" types of cases or subjects
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Review and reports on all types of "major" events
(such as deaths in the E.D.)
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Mechanisms for presentation of Q/A reports to
E.D. staff for education
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Mechanisms to contact patients and families regarding potential problems or complaints

 Daily audit of a random sample of prior day's charts
 Weekly or monthly audit of sampled charts
 Audit of all charts for a specified type of case for a defined period of time
 Audit of all charts for specified individual members of the E.D. staff
 Weekly or monthly meetings of staff designated as Q/A leaders or committee
 Regular verbal & written reports for education of E.D. staff

 Must have input from all the E.D. staff
 "Due process" must be assured (for protection of the staff's rights)
 It must be emphasized that the major goal of the Q/A system is improving patient care and educating the staff (not penalizing or criticizing the staff)
 Should be an "open" process even though confidentiality of patient's medical information must be assured

 Information from chart audits must be sent to E.D. leaders and administrators
 Information from chart audits regarding deficiencies must be communicated directly back to the E.D. staff
 Followup audits of identified deficiencies must be done to demonstrate correction or improvement
 Formal wriiten records of audits must be maintained in case future additional review is needed

 Missing documentation
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Mode of arrival
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Vital signs
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Allergies
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History components
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Exam components
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Lab results
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X-ray findings
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Consultations
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Disposition
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Follow-up instructions
 Missed tetanus immunizations
 Followup not listed for newly diagnosed hypertension
 Abnormal exam, lab,
EKG, or X-ray results not addressed
 Verification of attending supervision of resident and student cases

Chart Audit Items Which May Require
Phone Notification of the Patient
 Missed need for tetanus immunization
 Missed fracture or dislocation on X-ray
 Missed pneumonia or tumor on X-ray
 Misinterpreted EKG
 Abnormal lab value not addressed in original visit
 Positive blood or urine culture result
 Consultant or referral physician wants to have earlier than originally scheduled follow-up

Situations Requiring "Automatic"
Q/A Review and Report
 Death of patient in the E.D.
 Major injury to patient occuring in the E.D.
 Assault or major injury to E.D. staff
 Event requiring institutional "incident report"
 Complaint of major error by patient or family
 Complaint of major error by consultant or referral physician
 Potential life-threatening discrepancy noted on chart audit

 These should be compared for each E.D physician and group of E.D. personnel :
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Complaints registered by patients or families
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Patients leaving "against medical advice"
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Patients leaving prior to evaluation
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Unscheduled rechecks
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Wound complications (such as infections)
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Revisit for same problem within 7 days
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Mean time durations for evaluation, admission, or discharge
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Caseloads per unit time

 Followup for positive cultures reported by the hospital microbiology lab :
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Need to notify referral physician promptly
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May also need to notify patient directly
 If E.D. EKG "overreading" is done by cardiology, need to notify patient directly to come back to E.D. if ischemia was missed
 If major X-ray finding missed, need to notify patient directly or assure that referral physician notified and will follow up

 Best if daily chart Q/A audits are done by physician not assigned that day to clinical duty
 Probably best if specific staff designated as Q/A reviewers for better consistency
 Department leaders and administrators need to be directly involved
 Each type of department personnel must have input and specific Q/A system duties
 Data may be accumulated by non-clinical personnel, but only personnel with clinical experience should be responsible for review & interpretation