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Emergency medicine: A practice prone to error?

Published online by Cambridge University Press:  21 May 2015

Pat Croskerry*
Department of Emergency Medicine, Dartmouth General Hospital Site, Capital District Health Authority, Dartmouth, NS Department of Emergency Medicine, Dalhousie University, Halifax, NS
Douglas Sinclair
Department of Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS
Department of Emergency Medicine, Dartmouth General Hospital Site, Capital District Health Authority, 325 Pleasant St., Dartmouth NS B2Y 4G8; fax 902 465–1129,,


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The last decade has witnessed a rapidly growing public and academic interest in medical error, an interest that has culminated in the emergence of the science of error prevention in health care. The impact of this new science will be felt in all areas of medicine but perhaps especially in emergency medicine (EM). The emergency department’s unique operating characteristics make it a natural laboratory for the study of error. These characteristics, combined with the complex and myriad activities of EM, predict vulnerability to a multitude of errors. Overcrowding and other resource limitations impair continuous quality improvement, and many errors result from high decision density, excessive cognitive load and flawed thinking in the decision-making process. A large proportion of these errors have serious outcomes but an even higher proportion are preventable.

The historical practice of blaming individuals for errors needs to be replaced by root-cause analysis that identifies process and systemic weaknesses. Quantitative and qualitative methods are needed to detect, describe and classify error at all levels in the system. Research is needed into the processes that underlie EM error. Educational initiatives should be developed at all levels, for everyone from undergraduate trainees to practicing emergency physicians. Changes in societal attitudes will be an important component of the new culture of patient safety.

A nationwide reporting system is proposed to disseminate error information expediently. Canadian EM providers are in a pivotal position to provide leadership to the Canadian health care system in this important area.

ED Administration • Administration du DU
Copyright © Canadian Association of Emergency Physicians 2001


1.Croskerry, P.The cognitive imperative: thinking about how we think. Acad Emerg Med 2000;7:122331.CrossRefGoogle ScholarPubMed
2.Riegelman, RK.Minimizing medical mistakes: the art of medical decision making. Boston: Little, Brown and Co; 1991.Google Scholar
3.Bogner, MS, editor. Human error in medicine. Hillsdale (NJ): Lawrence Erlbaum Associates; 1994.Google Scholar
4.Youngson, RM, Schott, I.Medical blunders. New York: New York University Press; 1996.Google Scholar
5.Spath, PL, editor. Error reduction in health care. San Francisco: Jossey-Bass Publishers; 1999.Google Scholar
6.Dowie, J, Elstein, A, editors. Professional judgement. Cambridge: Cambridge University Press; 1988.Google Scholar
7.Kahneman, D, Slovic, P, Tversky, A, editors. Judgement under uncertainty: heuristics and biases. New York: Cambridge University Press; 1982.Google Scholar
8.Sharpe, VA, Faden, AI.Medical harm. Cambridge: Cambridge University Press; 1998.Google Scholar
9.Bosk, CL.Forgive and remember: managing medical failure. Chicago: University of Chicago Press; 1979.Google Scholar
10.Paget, MA.The unity of mistakes. Philadelphia: Temple University Press; 1988.Google Scholar
11.Klein, GA, Orasanu, J, Calderwood, R, Zsambok, CE.Decision making in action: models and methods. Norwood (NJ): Ablex Publishing Corp.; 1995.Google Scholar
12.Kohn, LT, Corrigan, JM, Donaldson, MS, editors. To err is human: building a safer health care system [report of the Institute of Medicine]. Washington: National Academy Press; 1999.Google Scholar
13.Shimmel, EM.The hazards of hospitalization. Ann Intern Med 1964;60:1001.CrossRefGoogle Scholar
14.Ogilvie, IG, Ruedy, J.Adverse reactions during hospitalization. CMAJ 1967;97:144550.Google ScholarPubMed
15.Mills, DH, Boyden, JS, Rubsamen, DS, editors. California Medical Association medical insurance feasibility study. San Francisco: Sutter; 1977.Google Scholar
16.Brennan, TA, Leape, LL, Laird, NM, Hebert, L, Localio, AR, Lawthers, AG, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study 1. N Engl J Med 1991;324:3706.Google Scholar
17.Gawande, AA, Thomas, EJ, Zinner, MJ, Brennan, TA.The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:6675.CrossRefGoogle ScholarPubMed
18.Wilson, RM, Runciman, WB, Gibberd, RW, Harrison, BT, Newby, L, Hamilton, JD.The quality in Australian health care study. Med J Aust 1995;163:45871.CrossRefGoogle ScholarPubMed
19.Vincent, C, Neale, G, Woloshynowych, M.Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:5179.CrossRefGoogle ScholarPubMed
20.Donaldson, L.How to take things forward [paper presentation]. In: Reducing Error in Health Care and Improving Patient Safety [conference of British Medical Association and British Medical Journal]; 2000 Mar 21; London.Google Scholar
21.Herridge, CF.Physical disorders in psychiatric illness: a study of 209 consecutive admissions. Lancet 1960;2:94951.CrossRefGoogle ScholarPubMed
22.Carlson, RJ, Nayar, N, Suh, M.Physical disorders among emergency psychiatric patients. Can J Psychiatry 1981;26:657.CrossRefGoogle ScholarPubMed
23.Hoffman, RS.Diagnostic errors in the evaluation of behavioral disorders. JAMA 1982;248:9647.CrossRefGoogle ScholarPubMed
24.Tintinalli, JE, Peacock, FW, Wright, MA.Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994;23:85962.CrossRefGoogle ScholarPubMed
25.Henneman, PL, Mendoza, R, Lewis, RJ.Prospective evaluation of emergency department clearance. Ann Emerg Med 1994;24: 6727.CrossRefGoogle ScholarPubMed
26.Wears, RL, Leape, LL.Human error in emergency medicine. Ann Emerg Med 1999;34:3702.CrossRefGoogle ScholarPubMed
27.Vincent, C, Simon, R, Sutcliffe, K, Adams, JG, Biros, MH, Wears, RL.Errors conference: executive summary. Acad Emerg Med 2000;7:11802.CrossRefGoogle ScholarPubMed
28.Croskerry, P.The feedback sanction. Acad Emerg Med 2000;7: 12328.CrossRefGoogle ScholarPubMed
29.Wu, AW, Folkman, S, McPhee, SJ, Lo, B.Do house officers learn from their mistakes? JAMA 1991;265:208994.CrossRefGoogle ScholarPubMed
30.Wu, AW.Medical error: the second victim. BMJ 2000;237:7267.CrossRefGoogle Scholar
31.Williams, JC.A data-based method for assessing and reducing human error to improve operational performance. In: Hagen, W, editor. 1988 IEEE 4th Conference on Human Factors and Power Plants. New York: Institute for Electrical and Electronic Engineers; 1988. p. 20031.Google Scholar
32.Reason, JT.Managing the risks of organizational accidents. Aldershot (UK): Ashgate; 1997.Google Scholar
33.Broselow, J.Broselow pediatric resuscitation tape. Self-produced.Google Scholar
34.Klein, G.Sources of power: How people make decisions. Cambridge (MA): The MIT Press; 1998.Google Scholar
35.Chisholm, CD, Collison, EK, Nelson, DR, Cordell, WH.Emergency department workplace interruptions: Are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med 2000;7:123943.CrossRefGoogle ScholarPubMed
36.Gillespie, K.Paramedics to defy hospital redirects: death of asthmatic teen sparks new order to bring most seriously ill patients to nearest emergency room. Toronto Star 2000 Jan 16.Google Scholar
37.Boyleand, T, Keung, N.Clement probing deaths from lack of hospital care: crowded ERs link 3 cases, coroner says. Toronto Star 2001 Jun 7.Google Scholar
38.Risser, DT, Rice, MM, Salisbury, ML, Simon, R, Jay, GD, Berns, SD, Consortium, Medteams. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med 1999;34:37383.CrossRefGoogle ScholarPubMed
39.Tepas, DI, Monk, TH.Work schedules. In: Salvendy, G, editor. Handbook of Human Factors. New York: Wiley; 1987. p. 81943.Google Scholar
40.Kassirer, JP, Kopelman, RI.Learning clinical reasoning. Baltimore: Williams and Wilkins; 1991.Google Scholar
41.Croskerry, P.Avoiding pitfalls in the emergency room. Can J Contin Med Educ 1996;Apr:110.Google Scholar
42.Bartlett, EE.Physicians’ cognitive errors and their liability consequences. J Healthc Risk Manage 1998;Fall:629.CrossRefGoogle Scholar
43.Kovacs, G, Croskerry, P.Clinical decision making: an emergency medicine perspective. Acad Emerg Med 1999;6:94752.CrossRefGoogle Scholar
44.Elstein, AS.Heuristics and biases: selected errors in clinical reasoning. Acad Med 1999;74:7914.CrossRefGoogle ScholarPubMed
45.Redelmeier, DA, Ferris, LE, Tu, JV, Hux, JE, Schull, MJ.Problems for clinical judgement: introducing cognitive psychology as one more basic science. CMAJ 2001;164:35860.Google ScholarPubMed
46.Epstein, RM.Mindful practice. JAMA 1999;282:8339.CrossRefGoogle ScholarPubMed
47.Kushniruk, AW, Patel, VL.Cognitive evaluation of decision making processes and assessment of information technology in medicine. Int J Med Inf 1998;51:8390.CrossRefGoogle ScholarPubMed
48.Bogner, MS.Human error in medicine: a frontier for change. In: Human error in medicine. Hillsdale (NJ): Lawrence Erlbaum Associates; 1994. p. 37383.Google Scholar
49.Barach, P, Small, SD.Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:75963.CrossRefGoogle ScholarPubMed
50.Vinen, J.Incident monitoring in emergency departments: an Australian model. Acad Emerg Med 2000;7:12907.CrossRefGoogle ScholarPubMed
51.Brennan, TA.The Institute of Medicine report on medical error: Could it do harm? N Engl J Med 2000;342:11235.CrossRefGoogle ScholarPubMed
52.Croskerry, P, Wears, RL, Binder, LS.Setting the educational agenda and curriculum for error prevention in emergency medicine. Acad Emerg Med 2000;7:1194200.CrossRefGoogle ScholarPubMed
53.Gosbee, JW.Human factors engineering is the basis for a practical error-in-medicine curriculum. In: Johnson, C, editor. Proceedings of the First Workshop on Human Error and Clinical Systems. Glasgow Accident Analysis Group Technical Report G99–1. Glasgow: Glasgow Accident Analysis Group; 1999.Google Scholar
54.Reynard, WD, Billings, CE, Cheaney, ES, Hardy, R.The development of the NASA aviation safety reporting system. NASA Publ 1114. Washington: National Aeronautical and Space Administration; 1986.Google Scholar
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