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Profiles in Patient Safety: A “Perfect Storm” in the Emergency Department
Author(s) -
Campbell Samuel G.,
Croskerry Pat,
Bond William F.
Publication year - 2007
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1197/j.aem.2007.04.011
Subject(s) - medicine , emergency department , medical emergency , process (computing) , commission , patient safety , intensive care medicine , nursing , law , health care , computer science , political science , operating system
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.