Profiles in patient safety: a "perfect storm" in the emergency department.

Samuel G. Campbell; Pat Croskerry; William F. Bond

Commentary

Profiles in patient safety: a "perfect storm" in the emergency department.

June 20, 2007

Campbell SG, Croskerry P, Bond WF. Acad Emerg Med. 2007;14(8):743-9.

View more articles from the same authors.

The authors present a case of delayed diagnosis and discuss the cognitive dispositions that can lead to diagnostic errors of commission in the emergency department.

PubMed citation

Available at

Related Resources From the Same Author(s)

Cognitive versus technical debriefing after simulation training.

April 12, 2006

From mindless to mindful practice—cognitive bias and clinical decision making.

July 31, 2013

Adaptive expertise in medical decision making.

October 17, 2018

The need for cognition and the curse of cognition.

October 3, 2018

Narrowing the mindware gap in medicine.

July 20, 2022

The importance of cognitive errors in diagnosis and strategies to minimize them.

March 6, 2005

Patient safety and diagnostic error: tips for your next shift.

February 3, 2010

Profiles in patient safety: authority gradients in medical error.

March 6, 2005

Airway carts: a systems-based approach to airway safety.

November 1, 2006

Profiles in patient safety: medication errors in the emergency department.

March 6, 2005

Cognitive debiasing; part 1 and part 2.

September 18, 2013

Emotional influences in patient safety.

October 20, 2010

Checklists to reduce diagnostic errors.

February 9, 2011

Distraction and interruption in anaesthetic practice.

January 23, 2013

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Quality, safety, and outcomes in anaesthesia: what's to be done? An international perspective.

December 20, 2017

Graduating pediatrics residents' reports on the impact of fatigue over the past decade of duty hour changes.

September 16, 2015

Residents report on adverse events and their causes.

January 4, 2006

The extent and importance of unintended consequences related to computerized provider order entry.

May 16, 2007

"Tech-check-tech": a review of the evidence on its safety and benefits.

October 5, 2011

To err is human: patient misinterpretations of prescription drug label instructions.

November 7, 2007

Improving diagnosis by improving education: a policy brief on education in healthcare professions.

September 12, 2018

Applying Lean methods to improve quality and safety in surgical sterile instrument processing.

March 13, 2013

When staff speak up on safety, do managers listen—and act?

August 24, 2011

Increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients.

April 13, 2011

Preprinted order sets as a safety intervention in pediatric sedation.

February 25, 2009

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Medication errors from over-the-counter cough and cold medications in children.

May 6, 2020

Misunderstanding of prescription drug warning labels among patients with low literacy.

June 7, 2006

Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.

December 12, 2007

Bias and racism teaching rounds at an academic medical center.

December 23, 2020

Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.

August 13, 2008

The use of simulation in emergency medicine: a research agenda.

March 7, 2007

Hospital leadership and quality improvement: rhetoric versus reality.

March 28, 2007

The impact of resident duty hour and supervision changes: a review.

December 9, 2015

Meaningful use of health information technology and declines in in-hospital adverse drug events.

March 8, 2017

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

August 15, 2007

Automated surveillance for adverse drug events at a community hospital and an academic medical center.

May 3, 2006

Assessing patient safety culture: a review and synthesis of the measurement tools.

November 8, 2006

Interhospital transfer patients discharged by academic hospitalists and general internists: characteristics and outcomes.

January 6, 2016

Errors and analysis of errors.

December 17, 2008

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.

February 2, 2022

Who makes prescribing decisions in hospital inpatients? An observational study.

May 30, 2012

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.

May 28, 2014

Competencies for improving diagnosis: an interprofessional framework for education and training in health care.

August 28, 2019

Computerized provider order entry adoption: implications for clinical workflow.

December 10, 2008

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

October 15, 2008

Assessing the anticipated consequences of computer-based provider order entry at three community hospitals using an open-ended, semi-structured survey instrument.

July 16, 2008

Types of unintended consequences related to computerized provider order entry.

September 20, 2006

Building a Patient Safety Toolkit for use in general practice.

July 20, 2016

Development of a medication safety and quality survey for small rural hospitals.

December 6, 2017

Rural hospital information technology implementation for safety and quality improvement: lessons learned.

August 5, 2009

Patient safety measures in burn care: do national reporting systems accurately reflect quality of burn care?

February 3, 2010

Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease.

March 6, 2019

Survey shows that at least some physicians are not always open or honest with patients.

February 22, 2012

Improving patient understanding of prescription drug label instructions.

January 21, 2009

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Impact of a computerized physician order-entry system.

June 3, 2009

Improving patient safety in radiation oncology.

March 16, 2011

Examining the diagnostic justification abilities of fourth-year medical students.

November 7, 2012

Nurse's Achilles Heel: using big data to determine workload factors that impact near misses.

April 14, 2021

Reducing unacceptable missed doses: pharmacy assistant–supported medicine administration.

February 18, 2015

Using human error theory to explore the supply of non-prescription medicines from community pharmacies.

August 23, 2006

Monitoring adverse drug reactions in children using community pharmacies: a pilot study.

June 29, 2005

Patient safety climate in hospitals: act locally on variation across units.

June 30, 2010

What 'just culture' doesn't understand about just punishment.

September 12, 2018

Clinical faculty: taking the lead in teaching quality improvement and patient safety.

October 8, 2014

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Patient misidentification in the neonatal intensive care unit: quantification of risk.

January 18, 2006

The effect of clinician feedback interventions on opioid prescribing.

April 27, 2022

Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services.

November 19, 2014

What is the scale of prescribing errors committed by junior doctors? A systematic review.

January 14, 2009

Implementing bedside handoff in the emergency department: a practice improvement project.

January 23, 2019

Tools for primary care patient safety: a narrative review.

November 26, 2014

Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture.

January 31, 2007

The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty.

September 12, 2018

Adversarial attacks on medical machine learning.

April 3, 2019

Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events.

September 21, 2011

Effect of illness severity and comorbidity on patient safety and adverse events.

November 9, 2011

Enhancing safety of a system-wide in situ simulation program using no-go considerations.

October 4, 2023

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

March 10, 2010

Professionalism in medicine: results of a national survey of physicians.

December 12, 2007

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study.

August 3, 2022

Analysis of a medication safety intervention in the pediatric emergency department.

January 24, 2024

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care?

September 11, 2019

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

November 1, 2006

Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors.

October 27, 2021

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

October 4, 2006

A comparison of hospital adverse events identified by three widely used detection methods.

August 5, 2009

Development of a trigger tool to identify adverse events and harm in emergency medical services.

September 20, 2017

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

February 17, 2016

Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework.

January 20, 2016

Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.

July 28, 2010

Handoffs causing patient harm: a survey of medical and surgical house staff.

October 1, 2008

Differences in the reporting of care-related patient injuries to existing reporting systems.

March 6, 2005

The gaps in specialists' diagnoses.

April 11, 2018

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.

February 25, 2015

Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff.

August 31, 2022

Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review.

August 6, 2008

Related Resources

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

Diagnostic delays among COVID-19 patients with a second concurrent diagnosis.

February 22, 2023

WebM&M Cases

Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.

July 8, 2022

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

WebM&M Cases

Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations

September 29, 2021

WebM&M Cases

Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks

June 30, 2021

Racial bias among emergency providers: strategies to mitigate its adverse effects.

May 26, 2021

Crisis checklists in emergency medicine: another step forward for cognitive aids.

April 7, 2021

Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution.

November 11, 2020

WebM&M Cases

The NSTEMI Curbside Consultation

July 29, 2020

WebM&M Cases

Misdiagnosis of a Pelvic Mass versus Pregnancy

July 29, 2020

Tolerance of uncertainty and the practice of emergency medicine.

July 15, 2020

WebM&M Cases

Getting the Diagnosis Both Right and Wrong

September 25, 2019

In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission.

July 31, 2019

A piece of my mind. Hard times and hard stops.

March 13, 2019

Pediatric Readiness in the Emergency Department.

November 1, 2018

Cognitive error in an academic emergency department.

October 10, 2018

Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims.

June 6, 2018

Vital signs: trends in emergency department visits for suspected opioid overdoses- United States, July 2016- September 2017.

March 21, 2018

Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey.

March 21, 2018

NHTSA Fatigue in EMS Project.

March 14, 2018

Ten ERs in Colorado tried to curtail opioids and did better than expected.

March 7, 2018

WebM&M Cases

Shortcuts to Acetaminophen-induced Liver Failure

March 1, 2018

WebM&M Cases

Missing ECG and Missed Diagnosis Lead to Dangerous Delay

March 1, 2018

Drug calculation ability of qualified paramedics: a pilot study.

February 28, 2018

Preventing mistransfusions: an evaluation of institutional knowledge and a response.

February 21, 2018

Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect?

February 7, 2018

Near-miss medication errors provide a wake-up call.

February 7, 2018

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.

January 31, 2018

Achieving the Institute of Medicine's 6 aims for quality in the midst of the opioid crisis: considerations for the emergency department.

January 10, 2018

See More About The Topic

Emergency Departments

Health Care Providers

Emergency Medicine

Cognitive Errors ("Mistakes")

Error Analysis

Profiles in patient safety: a "perfect storm" in the emergency department.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Profiles in patient safety: a "perfect storm" in the emergency department.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site