How Can ED Physicians Avoid Iatrogenic Patient Injuries?

Jason T. Nomura, MD


March 23, 2011


How can we reduce iatrogenic injury when performing procedures in the emergency department?

Response from Jason T. Nomura, MD
Associate Director, Emergency Ultrasound; Associate Director, Emergency Medicine Ultrasound Fellowship; Research Faculty, Department of Emergency Medicine; Core Stroke Faculty, Center for Heart and Vascular System, Christiana Care Health System, Newark, Delaware

Iatrogenic complications or injuries can be either early complications, such as mechanical errors, or late complications, such as procedure-related infections. Research has been more prevalent in central venous cannulation in varied settings, but findings can be extrapolated to other invasive procedures performed on a day-to-day basis in the emergency department (ED).

There are a multitude of things that can be done to help prevent complications from procedures that are performed at the bedside in the ED. Many interventions would need to be customized to the procedure, provider experience, and systems environment. However, there are 3 general safety precautions to help guide physicians.

Utilize Ultrasound

The first thing that can be done to prevent iatrogenic injury is to utilize ultrasound for procedural guidance. Data supporting real-time guidance of central venous cannulation at the internal jugular site has been accumulating since 2001, when the Agency for Healthcare Research and Quality (AHRQ) published their report, "Making Health Care Safer" with suggestions for improved patient safety. According to AHRQ data, ultrasound guidance was shown to reduce mechanical complications and increase success rates for central venous cannulation.[1]

However, it is not just ultrasound guidance but the appropriate use of ultrasound that has increased success rates. There have been recent studies and editorials looking at how we are performing ultrasound guidance. Tracking and visualizing the needle tip throughout the procedure in real-time can help to reduce mechanical complications, such as posterior wall or through-and-through punctures.[2]

Create a Checklist

A second step that can be utilized to help reduce errors is the use of checklists for procedures. Checklists can reduce late complications, such as central line-associated blood stream infections.[3] Checklists are also used to train healthcare providers to perform procedures, and to help reduce immediate and late complication.[4]

AHQR offers a sample checklist that can be downloaded from its Website. The Central Line Insertion Care Team Checklist features steps that have been shown to prevent central line-associated infection.

Practice, Practice, Practice

The third way for providers to reduce complications from procedures in the ED is no secret to seasoned doctors: experience. There is nothing that can replace the repeated practice of performing a procedure. However, the days of "see one, do one, teach one" and practicing on patients is long gone. We now have simulation equipment and task trainers to properly educate our novice practitioners. The use of simulation for education and skills practice has reduced error rates and helped to build and maintain skills.[4,5]