The Systems Approach to Error Reduction in the Emergency Department

Author: Charles D. Callahan, PhD, MBA, Administrator, Neuromuscular, Orthopaedics, and Emergency Services, Memorial Medical Center, Springfield, IL.

Peer Reviewer: Rollin J. Fairbanks, MD, Attending Physician, Department of Emergency Medicine, University of Rochester, Rochester, NY.

Few topics in medicine are as divisive as medical error. Since the publication of the Institute of Medicine’s report on medical errors, an enormous public and private response has called for strict emphasis on safety in every aspect of patient care. The emergency department (ED) as an entity is a set-up for medical error. In addition to the acute and often life-threatening conditions that present at any given moment, the modern ED is challenged by overcrowded conditions, a lack of available and accurate medical information, often sparse on-call specialty physicians, and a chaotic environment filled with distractions. Despite the difficult environment in which emergency physicians practice, patients deserve emergency medical care that is as error-free as possible.

In recent years, the analysis of complex system errors, such as medical errors occurring in the ED, has changed from simply labeling and punishing individuals to understanding the underlying systems that contribute to medical error. In this issue of Emergency Medicine Specialty Reports, error in the ED and its contributing factors will be discussed, as well as steps to develop a culture of safety. — The Editor


The Institute of Medicine (IOM) report, To Err is Human,1 was the health care equivalent of the shot heard round the world. The provocative assertion that more than 1 million injuries and nearly 100,000 deaths occur annually in the U.S. health care system due to medical errors has created public outrage, professional debate, and governmental inquiry.2-4 The ED appears to be at particular risk for the occurrence of medical errors. ED care is episodic and often marked by incomplete or absent past medical records, noisy physical environments, multiple distractions and interruptions,5 time pressure, crowding, and disrupted staff sleep cycles, all superimposed upon a complex mixture of patient complaints, conditions, and severities.6,7 Solutions to the problem of medical errors invariably invoke applications from the industrial quality movement and focus on topics such as human factors, cognitive information processing, and systems thinking.8 This issue of Emergency Medicine Specialty Reports will review today’s ED as a system under assault; examine data on safety within emergency medicine; provide a systems framework for assessing why errors occur and why well-intentioned efforts to improve error-prone processes too often fail; and suggest how best to intervene in the ED system to improve patient safety and outcome.

ED as a System Under Assault

Today’s ED is a unique system in a dramatic state of flux. Between 1997 and 2000, there was a 2% decrease in the number of U.S. EDs, resulting in a 16% increase in the average number of visits in the remaining centers.9 Increased volumes have exposed capacity problems that translate into longer waiting times for treatment and longer ED stays.10 Interacting with increased visit volumes are an array of issues that include: expansion in scope of emergency medicine care with pressure for rapid yet definitive final diagnosis; utilization by non-emergency patients for primary care needs; increased survival rates from critical illnesses/injuries due to advances in emergency medical services (EMS); and prolonged ED stays when hospital inpatient units and intensive care unit (ICU) beds are filled.11-15 ED crowding manifests in four ways that impact safety and quality of service delivery:16,17 diversion, boarding, leaving before medical evaluation, and prolonged patient pain/discomfort/frustration.

Diversion (or bypass) occurs when the hospital lacks staffing or resources to accept additional emergency patients, and redirects the flow of ambulances to other medical facilities. Amazingly, 69% of the nation’s EDs were on diversion at least one time during fiscal year (FY) 2001, and 10% were on diversionary status more than 20% of the time.9 Boarding is defined as retaining a patient in the ED after the decision has been made to admit him or her to the hospital, due to the immediate unavailability of an appropriate inpatient bed. In FY2001, 90% of EDs reported boarding patients two or more hours while waiting for a bed or transfer to another facility; 20% reported they boarded patients on average for at least 8 hours.9 Leaving before medical evaluation, also known as leaving without treatment (or LWOT), is most common among those persons triaged with apparently less severe conditions who are bumped by more emergent patients. Forty percent of the nation’s EDs report that 1-3% of registered patients leave before the medical evaluation. Of concern is research indicating that nearly half of such LWOTs were later judged to have needed immediate medical attention,9 and that approximately 10% of LWOTs in a large series subsequently were admitted to a hospital within one week of initial ED visit.15 These findings lead Asplin et al15 to suggest that LWOT rates may serve as a useful marker of adverse outcomes related to ED crowding.

For those who eventually are treated, extended waits and delays often lead to prolonged pain, discomfort, and frustration. This certainly complicates the eventual physician-patient interaction, and arguably relates to the findings from a national survey that ED patients are among the least satisfied hospital patients, with only 60% indicating they would recommend that ED to their family or friends.18 While it has been common to dismiss delays in care as an organizational deficiency, recent reports suggest time-to-treatment as an important predictor of clinical outcome in the ED.19 Notably, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has identified ED overcrowding as a source for more than half the reported sentinel event cases of patient death or permanent disability.17

The Scope and Nature of Errors in Emergency Medicine

While the exact magnitude of the problem of error in emergency medicine is unknown,20 accumulating evidence suggests that the ED has a higher proportion of adverse events than any other hospital department.21 In a recent study of nearly 2000 ED patient encounters, errors were detected in nearly 20% of the sample.7 Most errors were minor, with resulting adverse events occurring in only 1 of every 300 patients. The highest proportion of reported errors (22%) related to diagnostic accuracy. Similar results emerged in a series of more than 30,000 patient hospitalizations.21 While the ED accounted for only 3% of errors, 70% of these were judged to reflect missed diagnoses, making diagnostic errors among the most common mistakes that occur in the ED.22,23 A recent review24 demonstrated that ED physician and radiologist interpretation of radiographic images concurred approximately 90% of the time, though of those judged discrepantly, an alteration of treatment was indicated in up to 3% of cases. Failure to diagnose extremity fracture and identification of foreign body in a wound were the two most frequent causes of disagreement and malpractice action. Autopsy studies25,26 indicate a 4-15% rate of major diagnostic disagreement between ED and post-mortem diagnoses, though not of such degree as to have prolonged or guaranteed survival. Improvements in diagnostic technologies have failed to significantly reduce these error rates.27 Premature closure of search for alternate differential diagnostic possibilities, perhaps a reflection of perceived time-pressure under conditions of ED crowding, occurred in 91% of cases reviewed.28

Other ED activities with high numbers of errors were administrative procedures (such as errors in registration/admit/discharge or lost/mislabeled paperwork), medication delivery, communication, and environmental maintenance (like malfunctioning or misplaced equipment and supplies). No differences were found between categories of staff (i.e., physician, nurse, technician, or clerk), with a mean error-reporting rate of 5.5 errors per 100 hours worked. Based on these findings, the authors extrapolated that nationally more than 18 million errors and 360,000 adverse events occur each year in U.S. EDs.28

Lastly, considering the frequency of chest pain as the presenting chief complaint in ED, an interesting risk profile for such patients mistakenly discharged to home has been proposed.29 Such a patient is likely to be a woman younger than age 55, to be non-white, to have reported shortness of breath as the chief symptom, and to have normal or equivocal electrocardiogram (ECG). Of their sample of 10,000 ED patients incorrectly sent home, 200 actually met criteria for acute myocardial infarction or unstable angina and had a higher risk-adjusted mortality rate than those patients who were admitted to hospital.

Defining Quality and Error

According to the IOM,1 quality health care depends on three interacting domains: 1) safety, defined as freedom from accidental injury; 2) provision of services based on current medical evidence; and 3) meeting customer expectations. A consensus committee of the Society of Academic Emergency Medicine30 recommended the adoption of IOM definitions to reach the goal of improving emergency medical care for patients. (A summary appears in Table 1.) Error is defined as the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning); the accumulation of errors results in accidents.30-32 The committee further recommended that emergency medicine focus on identifying preventable and potential adverse events as the most direct way to improve the quality of emergency medical care.

Table 1. Summary of Recommended Definitions30

A preventable adverse event is when an injury occurs as a result of substandard medical care. A potential adverse event involves substandard care that could have resulted in injury (a near-miss). Experience in many high-risk industries indicates that significant numbers of adverse events can be prevented through the analysis of errors and the factors that contribute to and maintain error-prone processes.33 Leape and colleagues34 provide a useful categorization of the types of errors encountered in medical care. (See Table 2.)

Table 2. Types of Medical Errors34

The Systems Approach to Error Reduction

Two general approaches to understanding medical errors are found in the literature.6,32 The person approach focuses on the so-called sharp end of the intervention probe: the clinical providers on the front line providing patient care. Focus is on the health care worker’s mental and physical state at the time that the unsafe act occurred. Berwick35 argues that too often efforts at quality improvement in health care boil down to punitive attempts to remove the bad apples that produced the error. Such an approach sets a climate of fear, resistance, demoralization, and secrecy that impedes meaningful change.

Rather, most problems are built right into the complex care systems and procedures. Understanding and simplifying complex processes that produce errors from well-meaning, well-trained professionals is the hallmark of the systems approach that typifies the modern quality movement.36 A system is a set of interdependent elements interacting to achieve a common aim,30 and the systems approach focuses on the blunt end latent conditions that often pre-date the problematic patient care episode. Facility design, equipment selection (or non-selection), staff hiring, or work shift assignment decisions made in the past can return to importantly shape current outcome. Within the systems approach, Reason32 suggests that most care systems contain error but this gets distributed and masked by multiple process layers. Only when the holes in the system align does an adverse event manifest. Under this Swiss cheese model, root cause analysis frequently reveals five to 10 factors in interaction. None of these alone is sufficient to produce the poor outcome; all are necessary in combination to produce the adverse event.32,37 In one review of medical malpractice cases,38 an average of nine teamwork failures were reported per case. Thus, Leape2 points out that medical errors rarely are due to a single clinician’s personal failings, inadequacies, and/or carelessness. Faulty delivery systems (the blunt end) typically are at play and should be the focus of change. In an organization marked by a true commitment to error reduction and patient safety, there is a non-punitive system for error reporting, cataloguing, and analysis in an ongoing feedback loop.

Why Quality Initiatives in Health Care Fail

While the notion of importing best safety practices from other industries into health care is attractive, it must be acknowledged that the systematic yield over the past three decades has been fairly meager.39 Leape and Berwick, the leading advocates for such learning exchange, estimate that health care remains at least a decade behind other major industries in reducing process errors and defects. What factors lead to these disappointing conclusions?

First, conducting process change in the ED is like trying to change the fan belt on your car while the engine is still running. Due to the 24/7/365 operating hours, and relative lack of other redundant venues for care, EDs never really are taken off-line for retooling or repair. This is unique among high-risk industries. Aviation, manufacturing, and military organizations all regularly take operations centers out of service, typically on a pre-scheduled basis, to allow mechanical upgrades and staff education or rest and relaxation. Relatedly, benchmark safety industries have strict schedules for equipment refurbishment or replacement in a proactive approach to avoid system failure. This is not true in health care, where devices and infrastructure often are pushed long past their expected useful lives unless technology creep makes them unacceptable for use. With one-third of U.S. hospitals reporting negative total financial margins (i.e., they are paid less than the cost of delivering care)40 and six times as many hospitals receiving bond rating downgrades vs. upgrades in 2001,41 it appears unlikely that these trends will change any time soon. Liability concerns, information technology infrastructure limitations, and payment systems also are suggested to be unique impediments in health care.42

It also has been suggested that a relative void in emergency physician involvement in hospital quality initiatives (due to lack of time, interest, risk concerns, or lack of training/knowledge of how to participate) is a crucial barrier to change.39,42 As Leape2 has stated, in a culture of safety, errors are excusable but ignoring them is not. Hence, engagement by all ED staff in error reduction and providing them the context and tools for error reduction, are vital.

The Furthering Limitations of Human Cognition

Additional insights into the causes of systemic errors in the ED come from studies of human information processing. Despite the potential of truly incredible intellectual achievements, it must be admitted that the human brain is a system of limited cognitive processing capacity prone to a host of predictable judgment defects.43 Indeed, a primary conclusion of the extant medical error literature is that human information processing errors contribute to a large proportion of preventable adverse events.1,22,27,32,33,44-47

To deal with complex daily lives, the human brain assigns priorities to both incoming information and outgoing behavioral responses, and suppresses (or automatizes) conscious processing of trivial or redundant primary sensory inputs.48 People rely on intuitive judgment heuristics, or rules of thumb, to deal with the routines of daily life. (See Table 3.) Most of the time, these simplified automatic decision templates save time and yield correct results. However, the ED requirement of integrating complex interdisciplinary data at an escalating pace of production can overwhelm these heuristics. As a result, clinicians may over-diagnose impairment (labeling heuristic); attribute excessive significance to trivial predictors (availability heuristic); ignore statistical realities (regression toward the mean) or base rates; be unduly influenced by early features of the interview (anchoring effects); and/or discount or miss disconfirming evidence (representativeness heuristic and confirmatory bias).44,45,49

Table 3. Common Judgment Heuristics and Limitations

Despite the extensive literature on these pitfalls of human information processing, even highly trained physicians tend to overestimate the accuracy of their clinical predictions while remaining extremely confident about these predictions. Consequently, salient alternative sources of information may be overlooked or downplayed.50,51

Another class of influential yet frequently dismissed cognitive factors have been labeled "mechanics of judgment."52 Such factors as "serial order effects, position effects, contrast effects, and many types of anchoring effects … should seem particularly implausible as reasons for liking or disliking an object." Nonetheless, these mechanics of judgment may operate outside of awareness to importantly shape acceptance or rejection of important parameters like: differential diagnosis alternatives, diagnostic test selection, treatment alternatives, medication dosages, referral to consulting specialist physicians, decision to admit or discharge, use of physical or chemical restraint, incorporation of collateral others as sources of information, and follow-up referral planning. What is the impact of mechanics of judgment on the individualized care plan of the last patient treated within an 8- or 12-hour shift as opposed to the first?

Compounding these normal limitations of human cognition, the ED environment poses additional challenges to error-free performance in the forms of fatigue, workload, cognitive overload, disrupted interpersonal communication, incomplete patient information, and even anxiety about risk of personal harm from exposure to pathogens or violence.33 Physicians tend to overestimate their ability to perform under such adverse but common pressures.53 These issues may be even more pronounced in emergency medicine due to work patterns marked by rotating day/night work shifts. It has been shown that such shifts impact sleep-related cognitive recovery due to circadian rhythm disruption, manifesting in reduced information processing performance in ED physicians. This is most pronounced in visual memory, which may have clinical relevance for interpretation of ECG and diagnostic imaging studies.54

The key insight from the systems approach is that ED care processes must be built to be resilient despite these known limitations of human information processing. Safety and error-checking must be built into all levels of the care process so that the risk of the potential holes in the system lining up are significantly minimized.

Toward a Culture of Safety

Lasting, reliable, and capable patient care processes that are error resistant likely will come only with the development of a culture of safety within the ED.55 Organizational culture can be defined as a pattern of basic assumptions that is developed by a given group over time as it successfully adapts to internal and external threats, and that is taught to new group members as the correct way to adapt in the future.56 Cultural beliefs and values manifest through observable actions and artifacts (i.e., insignia, style of dress, etc.). The development of a safety culture requires activities that promote shared values, language, and artifacts that continually assert that safety is the top priority. Frequent communication of safety goals, safety success stories, and honest discussion of safety concerns will help to move individuals and teams toward this endpoint.

A Tool Box of Recommended Actions

Woolf has stated, "nothing is more contrary to the ethos of medicine than harming individuals who search for care and compassion."57 That many individuals are harmed while seeking help in EDs underscores the need for immediate action that takes a systems view of the care process. Increased understanding of the truly human factors that can facilitate or derail quality improvement initiatives is needed. Emergency physicians must play an active leadership role in driving an accountability-based safety culture in which every error is our error.19 Blind faith in technology will be faith unrewarded. As has been learned in many industries, technology can accelerate quality and productivity gains, but it cannot create them.58 Rather technology must stem from and reflect the core mission and vision of the organization, and that mission/vision must be an enlivened focus on safety.

Stemming from this review, the following items constitute a collective tool box for use in this quest to achieve meaningful error reduction in the ED:

• Develop ED physician leaders who personally are committed to making a reality the IOM goal of reducing medical errors by 50% during the next five years; allocate needed time, training, and resources to ensure that they can maintain focus on key safety goals.

• Promote movement to a culture of safety marked by transparency of safety successes and lapses to promote team learning and process improvement. While errors may be excusable, denying or ignoring them is not.

• Identify and address motivational and/or knowledge features within individuals or teams to overcome resistance to change.

• Consider ergonomic factors (i.e., shift schedules, ambient lighting, visibility and proper location of needed equipment, standardization in device designs and manufacturers of ED equipment)59 and aggressively address any factors plausibly related to safety risk in the department.

• Build in cognitive forcing strategies such as clinical practice guidelines (CPGs),60 reminders, and checklists for charting and prescriptions61 to reduce risk of cognitive errors. Such strategies are based on the premise that proper cueing can effectively prompt needed action. Recognition memory is more reliable then free recall memory, thus order sets or documentation templates that push memory triggers at staff reduce the likelihood of errors of omission.

• Invest significantly in staff training and education. More so than almost any other high-risk industry, those in health care assume that staff know how to operate, maintain, and/or troubleshoot essential equipment, or respond to extraordinary events in some unified predictable way. Health care practitioners need to be more stringent about competency check-offs that ensure that personnel have been drilled to perform needed actions by habit, not by luck. Ongoing training must be built into the work schedule, and participation enforced, to achieve meaningful error reduction.

• Seek alliances with other disciplines to provide checks and balances (as with radiologist over-reads of ED diagnostic studies and verbal order read backs to ensure accurate comprehension) and to act as naïve savants when evaluating the most trusted ED processes for potential defects.

• Employ measurement to realistically portray ED performance. Such measurement continually must be presented to all ED staff, and is a prime component of the Plan-Do-Study-Act (PDSA) rapid-cycle improvement model.62 Statistical process control (SPC)63 is a robust yet practical analytical and data presentation technique that is well matched to the ED environment.

• Continually seek to reduce unnecessary ED waits and delays through use of PDSA and SPC techniques, and thereby reduce potential for pain, suffering, frustration, and medical complications in the patients served.

• Seek benchmark information on best practices, and deploy rapid-cycle change methods to aggressively incorporate best ideas into the department. The recent Urgent Matters64 and JCAHO Core Measures65 initiatives offer ED-relevant guidance on best practices to improve the efficiency and effectiveness of care.

• Deploy information technology to extend and support, though not create, positive process change.58 Personal wireless phone devices can increase point-to-point communication within the ED while simultaneously reducing ambient distracting background noise. Current-generation computerized/electronic medical record (EMR) systems can provide vital access to historical and current patient information to facilitate decision-making. Next-generation EMRs will provide safety surveillance capabilities that alert providers to potential adverse drug interactions or other patient-specific safety alarms.

• Conduct analyses of errors without blame or coercion while reinforcing the expectation of accountability by all participants.

• Work to move all stakeholders to the highest level of perceived accountability, where safety is everyone’s job and it is a shared responsibility.


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CME Objectives

Upon completing this program, participants should be able to:

  • understand medical error prevention in the emergency department setting;
  • identify factors involved in medical errors; and
  • identify methods to help reduce medical errors;

Physician CME Questions

To participate in this CME program, read the article and then answer the questions below. Review any material related to missed questions. In order to receive credit for this activity, you must complete the evaluation form enclosed with this issue. When your completed form has been received, a certificate will be mailed to you.

1. The person approach to error reduction focuses on:

A. staff hiring or shift assignment decisions.
B. the clinical providers giving patient care.
C. latent conditions that pre-date a problematic patient care episode.
D. facility design.

2. The systems approach to error reduction focuses on:

A. the blunt end of intervention.
B. latent conditions that pre-date a problematic patient care episode.
C. factors such as facility design, equipment selection, staff hiring, and shift assignments.
D. All of the above

3. Human information processing errors contribute to a large proportion of preventable adverse events.

A. True
B. False

4. The limitation of confirmatory bias is:

A. extreme and rapid data reduction leading to over- or misdiagnosis.
B. attributing excessive significance to trivial predictors.
C. perceiving only those data that confirm prevailing diagnosis or classification.
D. overinterpretation of performance fluctuations as indicative of clinical change.

5. Which of the following factors contribute to the difficulty of conducting process change in the ED?

A. Continuous operating hours
B. Lack of other redundant venues for care
C. Liability concerns
D. Information technology infrastructure limitations
E. All of the above

6. Steps to promote an error free culture in the ED include:

A. using clinical practice guidelines (CPGs) reminders and checklists for charting.
B. investing in staff training and education.
C. reducing ED waits and delays.
D. benchmarking best practices.
E. All of the above

7. The most common source of error in the ED is:

A. medication delivery.
B. malfunctioning equipment.
C. diagnostic errors.
D. administrative procedures.

CME Answer Key

1. B; 2. D; 3. A; 4. C; 5. E; 6. E; 7. C