Would you have done something differently? A novel marker for improving emergency care

Health care quality reviews are often thought to be of limited value as they react to human behavior rather than reflect varied processes throughout the healthcare system.

To evaluate if questioning ED physician reviewers as to whether they would have done something differently (WYHDSD) can be a useful marker to improve patient care processes in the emergency department.

Prospective data were collected on all patients presenting to an academic medical center ED with an annual census of 55,000 patients between November 2017 and November 2021. All cases who met the following standard criteria were identified for review by an electronic medical record system: 1) returned to the ED within 72 h and admitted on second visit; 2) admitted from the ED to the floor and then transferred to the ICU within 24 h; 3) expired within 24 h of ED arrival; or 4) were referred to the QA committee as the result of physician or patient complaints. Cases were randomly assigned to EM physicians not involved in the patient's care. After cases were reviewed using a structured electronic tool to assess for error and adverse events, reviewers were mandated to report whether they would have done anything differently (WYHDSD) in the management of the case. If a reviewer answered affirmatively, they were required to document specifics in a narrative format.

During the study period, 6773 cases were reviewed. There were 815 cases where reviewers would have done something differently. In 297 cases, reviewers would have done something differently even though there were no near misses or adverse events found by standard QA reviews. Of those 297 cases, 261 of the WYHDSD responses were found to be due to 1 of the 5 following issues: communication, not acting on data acquired, not acquiring necessary information, systems issue/preventative measures, and knowledge gaps of clinicians.

Asking reviewers if they would have done something differently could potentially be a useful quality marker to improve patient care systems in the ED even in cases where reviewers did not identify errors or adverse events.