title: Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the emergency department.
abstract: This article presents a model of how a build-up of interruptions can shift the dynamics of the emergency department (ED) from an adaptive, self-regulating system into a fragile, crisis-prone one. Drawing on case studies of organizational disasters and insights from the theory of high-reliability organizations, the authors use computer simulations to show how the accumulation of small interruptions could have disproportionately large effects in the ED. In the face of a mounting workload created by interruptions, EDs, like other organizational systems, have tipping points, thresholds beyond which a vicious cycle can lead rather quickly to the collapse of normal operating routines and in the extreme to a crisis of organizational paralysis. The authors discuss some possible implications for emergency medicine, emphasizing the potential threat from routine, non-novel demands on EDs and raising the concern that EDs are operating closer to the precipitous edge of crisis as ED crowding exacerbates the problem.
authors.affiliation: Brandeis International Business School, Waltham, MA, USA. bmorriso@brandeis.edu
authors.forename: J Bradley
authors.initials: JB
authors.lastname: Morrison
authors.forename: Jenny W
authors.initials: JW
authors.lastname: Rudolph
mesh_terms: D000060:Accidents, Aviation; D001288:Attention; D004635:Emergency Medicine / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007858:Learning; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D019982:Organizational Case Studies; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration; D010818:Practice Patterns, Physicians' / Q000458:organization & administration; D013315:Stress, Psychological; D013647:Task Performance and Analysis; D016526:Workload