Profiles in patient safety: A "perfect storm" in the emergency department.
Correct and rapid diagnosis is pivotal to the practice of emergency medicine, yet the chaotic and ill-structured emergency department environment is fertile ground for the commission of diagnostic error. Errors may result from specific error-producing conditions (EPCs) or, more frequently, from an interaction between such conditions. These EPCs are often expedient and serve to shorten the decision making process in a high-pressure environment. Recognizing that they will inevitably exist, it is important for clinicians to understand and manage their dangers. The authors present a case of delayed diagnosis resulting from the interaction of a number of EPCs that produced a "perfect" situation to produce a missed or delayed diagnosis. They offer practical suggestions whereby clinicians may decrease their chances of becoming victims of these influences.
Campbell
Samuel G
SG
Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. emsgc@cdha.nshealth.ca
Croskerry
Pat
P
Bond
William F
WF
D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000628:therapy; D001291:Attitude of Health Personnel; D003657:Decision Making; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D004635:Emergency Medicine / Q000379:methods; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D005260:Female; D006801:Humans; D007400:Interprofessional Relations; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy; D008875:Middle Aged; D010360:Patient Transfer; D010818:Practice Patterns, Physicians'; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods; D018570:Risk Assessment; D017751:Safety Management; D012640:Seizures / Q000175:diagnosis* / Q000628:therapy