Emergency Medicine: A practice prone to error? CJEM 2001 Oct;3(4): 271-276.
This classic article by Drs. Croskerry and Sinclair, pioneers in the study of emergency medicine error, is just as relevant now as it was when it was written 15 years ago.
On the unknown scale of the problem of errors:
“The first report dealing with emergency department (ED) error did not appear until 1999…Most studies describe outcomes of hospitalized patients; therefore, the extent of error in the ED is largely unknown…These studies probably underestimated the rate of ED error, because they examined only the records of hospitalized patients. Diagnostic and therapeutic errors undoubtedly occurred among patients discharged from the ED without being admitted, and these would only come to light ift he patient returned to the same ED and if there was a systematic feedback mechanism to identify the problem. Furthermore, when such errors are discovered, inappropriate defence mechanisms such as secrecy, denial, projection and blaming often inhibit learning from the event.”
On factors predisposing to error:
“First, the patients are usually unknown to the physicians and nurses, and the patient information available to the ED staff does not match in continuity and completeness the history that would be available to the patient’s family doctor. This problem is compounded by the relatively short time available for patient assessment and by the overall imperative to think and act quickly. Second, decision density (the number of decisions that the physician must make during a shift) and cognitive load (the background information that the physician must bring to bear on those decisions) appear to underlie many cognitive errors. Common ED problems such as weakness, dizziness, and chest or abdominal complaints have a wide differential diagnosis and carry a high degree of diagnostic uncertainty. The combination of high decision density and diagnostic uncertainty leads to high error prevalence. The large number of physical, laboratory, radiographic and electrocardiogarphic examinations performed in the ED, and the need to accurately interpret their findings also increases decision density and cognitive load…Thirdly, the level of experience of physicians and nurses is intrinsically linked to preventability of error…Another problem is the lack of feedback emergency physicians receive, from within the ED and from other specialties, medical records departments and the coroner’s office. Without timely and reliable feedback, acquisition and maintenance of cognitive, procedural and affective skills can be compromised. All of these potential sources of error are compounded by shift work. Changeover from one physician or nursing shift to another disrupts care and increases the chance of error. Circadian rhythm disturbance and fatigue associated with night work lead to cognitive errors and impaired performance. Many medical errors result from flaws in thinking that affect clinical decision-making. Physicians and nurses, especially those working in the ED, are frequently unaware of how they evaluate the often haphazardly gathered evidence at their disposal.”
On detection of error:
“The nature and extent of ED error is poorly defined. Current reporting mechanisms (eg incident reports) fail to capture up to 96% of errors. Lack of feedback prevents detection of and learning from errors; therefore it is critical to develop improved feedback mechanisms…Morbidity and mortality (M&M) rounds are one avenue for open discussion of error in clinical case management; however, they may be subject to a number of biases. Case management may appear in retrospect better or worse than it actually was, sometimes because the conditons under which the original decisions were made are not reproducible and sometimes because other variable that exerted an influence at the time have been forgotten..Esoteric cases, which may be colourful but contribute little to clinical learning, are overrepresented in M&M rounds. These rounds should focus on cases that represent typical management problems or adverse outcomes, including ambient conditions at the time.”
On a need for a cultural shift:
“A critical aspect of the new culture of patient safety is the need to chance societal attitudes toward medical error. Current error theory judiciously shifts the focus from individual blame to a better understanding of system andn process factors. Just as many clinicians must become better acquainted with error theory, the public will also need to acquire a more realistic understanding of the fallibility of health care providers and the system in which they practice. Considerable efforts will be required to overturn traditional attitudes toward medical error.”