Discussion
We present the first overarching consensus-based patient safety research priorities developed for emergency medicine. Previous work has suggested a potential disconnect between safety concerns identified by national bodies in charge of patient safety and those identified by emergency medicine physicians [
9]. Concerns ranked highly by emergency physicians, but not previously considered in national patient safety initiatives, include the effects of the availability of expert consultation and of follow-up care on patient safety [
9]. This is also in keeping with findings that unintended patient safety events in the ED are often related to cooperation with other departments [
10]. These concerns were identified by our expert panel and highlight the need to understand the influence of coordination/transition issues across the continuum of patient care on patient safety events.
Research priorities for patient safety specifically within the context of ED crowding have been published [
11]. While both this work and ours involved expert, consensus-based recommendations, the scope of priorities identified in our process provides a broader agenda for patient safety research in emergency medicine, beyond ED crowding. Both processes identified the need to develop innovative and novel methods outside the conventional clinical investigative techniques to measure, evaluate, and understand patient safety events. Our priorities align well with research agendas laid out by large national patient safety organizations. The five areas of research focus identified by the National Patient Safety Foundation [
12] are reflected in our priorities to develop and evaluate methods to identify and understand patient safety problems, understand human and environmental factors related to patient safety, and evaluate interventions that aim to improve patient safety in the ED. Our priorities are also reflected within the patient safety research agenda set by the Agency for Healthcare Research and Quality which include understanding the epidemiology of medical error and patient safety, issues related to transitions of care, and understanding and evaluating interventions to improve patient safety [
13]. Finally, our priority to understand how transitions across the continuum of care is one of the six priority areas for patient safety research identified by the WHO [
14]. Our focus on ED-specific research priorities also fits well within the WHO goal of focusing research on identifying locally effective and affordable solutions and local research priorities [
14].
As highlighted by our guiding principles, the next step in furthering the patient safety research agenda in the ED setting is for researchers to align with safety scientists to explore novel research methods to address the priorities we identified. Examples of novel research methods that have been identified for application in patient safety research include methods from engineering such as process mapping and probabilistic risk assessment, direct observation using ethnographic approaches, and methods from organizational psychology and sociology to assess organizational culture. Collaboration across disciplines is essential to determine the optimal research method, or methods, to translate this agenda into relevant and feasible research that will improve patient safety in the ED [
15].
Limitations
Although we engaged a wide selection of stakeholders including individuals with considerable experience in patient safety and patient safety research, representatives from patient advocacy groups, large funding agencies, and safety science (such as human factor engineers, complex systems experts, psychologist, and social scientists) were not involved and could have provided additional contributions to the research agenda. Furthermore, although the response rate to our initial survey for suggested priorities was low at 35.2%, when we examined our low response rate, it was primary related to the poor response from community ED directors and we sent multiple responders to non-responders in an attempt to improve response rates. It is difficult to interpret the low response rate from community ED directors, and it may reflect multiple administrative demands on their time. It is unlikely a reflection of their lack of interest in patient safety. It is important to note that we purposefully sampled a wide audience in an attempt to seek input from individuals who were outside the area of patient safety research. Next steps could involve reviewing the identified priorities with safety scientists to gain further insights into important patient safety research topics that may not be typically discussed in the clinical setting.
Acknowledgements
Financial support for this project, including all travel and the in-person meeting, was provided by a peer-reviewed grant from the Canadian Institutes of Health Research. The funding agency had no role in the design, conduct, or reporting of this study or decision to submit for publication. No industry funding supported this project. Dr. Newton is supported in part by a CIHR New Investigator Award (2012 to 2018). Dr. Plint is supported in part by a University of Ottawa Tier 2 Clinical Research Chair (2010 to 2015).
Priorities in Patient Safety Research in Emergency Medicine Consensus Panel*:
Stacy Ackroyd-Stolarz, MSc, PhD, Department of Emergency Medicine, Dalhousie University and Capital District Health Authority, Halifax, Nova Scotia, Canada (stacy.ackroyd@dal.ca); Maala Bhatt, MD, MSc., Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada** (mbhatt@cheo.on.ca); James Chamberlain, MD, Emergency Medicine, Children's National Medical Center and Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA (jchamber@childrensnational.org); Karen Cosby, MD, Department of Emergency Medicine, Rush University Medical School and Department of Emergency Medicine, Cook County Hospital (Stroger), Chicago, Illinois, USA (kcosby@cookcountyhhs.org): Ken Farion, MD, Departments of Pediatrics and Emergency Medicine, University of Ottawa and the Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (farion@cheo.on.ca); Olavo Fernandes, PharmD, Pharmacy, University Health Network and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (olavo.fernandes@uhn.ca); Abigail Hain, Canadian Patient Safety Institute, Ottawa, Ontario, Canada (ahain@cpsi-icsp.ca); Mona Jabbour, MD, MEd, Departments of Pediatrics and Emergency Medicine, University of Ottawa and the Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada (jabbour@cheo.on.ca); Amanda S Newton, RN, PhD, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada (an6@ualberta.ca); Adam Oster, MD, FRCPC, Foothills Medical Center, Alberta Children's Hospital, and Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada (adam.oster@albertahealthservices.ca); Richard M Ruddy, MD, Cincinnati Children's Hospital Medical Center and Department of Pediatrics at the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA (richard.ruddy@cchmc.org); Kathy Shaw, MD, MSCE, The Children's Hospital of Philadelphia and Department of Pediatrics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA (shaw@emaiil.chop.edu); Doug Sinclair, MD, CCFP (EM), FRCPC; St Michael's Hospital and Emergency Medicine, University of Toronto, Toronto, Ontario, Canada (sinclaird@smh.ca); Kim Stelmacovich, MHSc, Canadian Patient Safety Institute, Ottawa, Ontario, Canada (kimstelmacovich@cogeco.ca); James Stempien, MD, CCFP- EM, Emergency, Saskatoon Health Region and Clinical Assistant Professor, University of Saskatchewan, Saskatoon, Saskatchewan, Canada (stempien@islandnet.com); Robert Wears, MD, MS, PhD, Department of Emergency Medicine, University of Florida, Jacksonville, Florida, USA and Imperial College London, London, UK (wears@ufl.edu)
*Consensus Panel also included authors Amy C Plint, Antonia Stang, and Lisa A Calder.
**At the time of the consensus conference, Maala Bhatt was a member of the Department of Pediatrics, McGill University, Montreal, Quebec.
This work was presented at the Annual Meeting of the Canadian Association of Emergency Physicians, Vancouver, British Columbia, June 2013. It has been published only in abstract form.
Competing interests
Robert L Wears is an Associate Editor for Annals of Emergency Medicine and sits on the editorial board for the Journal of Patient Safety, for International Journal of Risk and Safety in Human Care, and for Human Factors. The remaining authors declare that they have no competing interests.
Authors’ contributions
ACP, AS, and LC conceived the consensus process, designed the methods, and obtained the research funding. ACP was responsible for overseeing research staff in administering surveys used in this study and for approaching possible expert panel members. ACP, AS, and LC were responsible for analyzing the data obtained in the survey process. AS was responsible for facilitating the expert panel meeting. ACP drafted the manuscript, and all authors contributed substantively to its revision. All panel members participated in the consensus process (both survey and in-person meeting), developed research priorities, and contributed substantially to revision of the manuscript. All authors read and approved the final manuscript.