Challenges of the Emergency Care Environment

Emergency care services are delivered in an environment where the need for haste, the distraction of frequent interruptions, and clinical uncertainty abound, thus potentially exposing patients to a number of threats to safety. Children are, of course, at particular risk under these circumstances because of their physical and developmental vulnerabilities and their inability to describe their symptoms and past medical history accurately, and because they may require care from providers who are not accustomed to treating pediatric patients (see Chapter 4).

EDs are high-risk environments for medical care for patients of all ages. The nature of their mission and the multiple challenges they confront increase the risk of medical errors and adverse events (Leape et al., 1991; IOM, 2000; Vinen, 2000; Weingart et al., 2000). In their study of admissions to hospitals in Colorado and Utah, Thomas and colleagues (2000) found the ED to be the hospital department with the highest proportion of negligent adverse events (52.6 percent). An earlier study by Trautlein and colleagues (1984) found that 15 to 20 percent of hospital malpractice claims were a result of errors in the ED, most of which involved serious injury or death (Trautlein et al., 1984).

There are several reasons why the ED is an area of high risk for errors. First, many EDs face excessive crowding, resulting in a noisy, even chaotic environment with frequent workflow interruptions. The large volume of patients results in many being evaluated, treated, and housed in the ED hallways, creating situations fraught with opportunities for error (Cosby, 2003; Selbst et al., 2004; Weiss et al., 2004). Moreover, ED patients do not arrive on a scheduled basis. Therefore, ED volumes can fluctuate a great deal, which makes it difficult to make staffing adjustments to meet sudden shifts in demand (Chamberlain et al., 2004).

Second, ED personnel often work under a great deal of stress. They are required to see a broad case mix of patients and make rapid clinical decisions with little time and often without sufficient patient information (Selbst et al., 2004). Most physicians manage one patient at a time (in the operating room, clinic, diagnostic suite, or outpatient surgical center); emergency physicians, by contrast, are often responsible for the simultaneous management of 10 to 20 patients or more with a variety of problems and different levels of acuity. This is such an intrinsic part of emergency medical practice that the oral board exam administered by the American Board of Emergency Medicine (ABEM) requires examinees to properly handle three hypothetical cases simultaneously. No other specialty incorporates multiple patient encounters in its board certification examination process.

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