Research

Using Medical Emergency Teams to detect preventable adverse events

Akshai Iyengar¹ , Alan Baxter² and Alan J Forster^1,3

¹  Department of Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada

²  Department of Anaesthesia, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada

³  Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, ON, K1Y 4E9, Canada

author email corresponding author email

Critical Care 2009, 13:R126doi:10.1186/cc7983

Published:	30 July 2009

See related letter by Stamel and Mehler, http://ccforum.com/content/13/5/420 and see related commentary by Amaral and Smojania, http://ccforum.com/content/13/5/194

Abstract

Introduction

Medical Emergency Teams (METs), also known as Rapid Response Teams, are recommended as a patient safety measure. A potential benefit of implementing an MET is the capacity to systematically assess preventable adverse events, which are defined as poor outcomes caused by errors or system design flaws. We describe how we used MET calls to systematically identify preventable adverse events in an academic tertiary care hospital, and describe our surveillance results.

Methods

For four weeks we collected standard information on consecutive MET calls. Within a week of the MET call, a multi-disciplinary team reviewed the information and rated the cause of the outcome using a previously developed rating scale. We classified the type and severity of the preventable adverse event.

Results

We captured information on all 65 MET calls occurring during the study period. Of these, 16 (24%, 95% confidence interval [CI] 16%–36%) were felt to be preventable adverse events. The most common cause of the preventable adverse events was error in providing appropriate therapy despite an accurate diagnosis. One service accounted for a disproportionate number of preventable adverse events (n = 5, [31%, 95% CI 14%–56%]).

Conclusions

Our method of reviewing MET calls was easy to implement and yielded important results. Hospitals maintaining an MET can use our method as a preventable adverse event detection system at little additional cost.