The effect of visitation restrictions on ED error

Abstract

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients-actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

Keywords: Emergency; Error; Visitation restrictions.