Perspective

Emergency medicine has evolved from a location, with variably trained and experienced
providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus
on the diagnosis and care of undifferentiated acute problems. The importance of rapid diagnosis
and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has
made timeliness not simply a determinant of patient satisfaction but also a significant safety and
quality concerndelays in care can be deadly. Emergency physicians (EPs) have identified
delays caused by crowding from boarding of admitted patients as their most significant safety
problem. We present a model for understanding emergency department (ED) patient safety and
identify solutions by deconstructing care into three realms: individual provider, patient, and
environmental system.
Individual Provider Issues
The EP workforce is diverse, and practitioners have varied training and experience. Of almost
40,000 practicing EPs in the United States, only 22,000 are board certified in emergency
medicine. Physicians lacking board certification may be inadequately trained. Nevertheless, the
need for nonboard-certified EPs is partly due to a significant shortage in trained EPs, a shortage
that is expected to continue for at least 20 years despite the 143 emergency medicine residency
programs currently operating in the United States. The workforce problem is particularly severe
in rural areas.
Less experienced EPs make more errors than those with experience. Moreover, physicians
entering practice without emergency medicine residency training often learn on the job, without
the benefit of experienced mentors. Inadequately trained physicians, combined with limited
specialty consultation support, create a serious safety risk for patients in rural EDs. Addressing
the training, experience, and general competence of physicians practicing in EDs requires
multiple strategies: increasing the number of emergency medicine residency trainees; adding EPsupervised midlevel providers; retaining experienced EPs who are considering retirement; and
providing training and support for nonED-residency-trained, nonboard-certified physicians
practicing in EDs. Making specialty consultation available through telemedicine can supplement
on-site consultation in areas where in-person consultation is limited.
ED physicians face cognitive challenges not commonly confronted by other physicians. The ED
is a 24/7 operation, and providers often work at night. Rotating shift work disrupts sleep, causes
fatigue, and creates problems with thinking, memory, and decision making. Lack of sleep is
associated with increased medical error. To address fatigue and sleep-related cognitive problems,
appropriate shift scheduling that recognizes research on sleep and performance should be
encouraged or mandated. Physicians can improve alertness and efficiency during night shifts by
using short naps during night shifts and limiting consecutive night shifts except when a night
float system is used.
Individual Patient Issues

Many patient characteristics create diagnostic challenges, particularly in patients who are elderly,
burdened with chronic disease, and not previously known to the provider or health care system.
The ED often acts as the health care entry point for uninsured patients who lack a primary care
provider to offer follow-up. Other sources of problems include providerpatient language
barriers, challenges with medical literacy, psychiatric or neurological diseases, homelessness,
and substance or alcohol abuse. Although interpreter services, telephone translation, and
interconnected electronic medical records provide some support, the lack of follow-up
(particularly for uninsured patients) complicates efforts to diagnose diseases that are early in
their evolution or present atypically. Other patient characteristics associated with fatal errors
linked with ED visits include unexplained abnormal vital signs, unrecognized decompensation of
chronic disease, and impaired communication or follow-up compliance.
Potential solutions to safety problems associated with the ED patient population include (i)
broadly available professional interpreter services for patients with limited English proficiency;
(ii) development and implementation of education, consultation, and support services oriented to
the management of patients with chronic diseases; (iii) recognition of high-risk patients with
appropriate alerts built into the care process and use of decision aids that help structure problem
analysis and resolution and (iv) provision of follow-up, patient education, and on-going care in a
comprehensive primary care practice (i.e., "medical home").
Environmental System Issues
The ED care environment can be a significant source of safety problems. Inadequate staffing
with nurses, physicians, and consultants; problems with teamwork; and inadequate continuity of
care can harm patient safety. Financial and workforce constraints may drive ED staffing to levels
that, while adequate for average ED volumes, are not adequate for higher volume days.
Additionally, some patients will leave without being seen when ED volume is high, increasing
the risk of bad outcomes. Excessive noise, repeated interruptions, inadequate space to see
patients, and delays or inaccuracies in laboratory and radiologic study results create additional
environmental burdens. These problems can delay diagnosis and treatment or lead to errors due
to breaks in procedural routine. Because emergency care requires the cooperation of multiple
physicians, failure to accurately transfer information between them can result in incorrect
decisions and time-consuming repetition of studies.
The practice of boarding admitted patients in the ED creates the greatest environmental
contributor to safety problems. ED crowding has steadily worsened due to increasing numbers of
ED patient visits, fewer hospital EDs, and a lack of commensurate increase in inpatient hospital
beds for our growing population. The boarding of newly admitted patients in the ED creates a
huge burden on ED nurses because of the resources needed for newly admitted patients and lack
of familiarity of ED nurses with inpatient nursing procedures. Filling ED beds with inpatient
boarders crowds other patients into hallways, waiting rooms, and other non-private areas.
Confidential information cannot easily be obtained, and physical examinations are severely
limited. Solutions to boarding in the ED have been advocated. In Great Britain, government
policy strictly limits ED length of stay. Unfortunately, despite growing evidence of the risks of
ED boarding, patient safety regulatory organizations such as The Joint Commission and the

Centers for Medicare & Medicaid Services have not developed or enforced effective limits on
ED boarding.
There are several potential solutions to address environmental system issues. (i) Nurse and
physician staffing should build in adequate buffers for high-volume periods, so that delays in
care and task saturation are avoided. (ii) Boarding of admitted patients in the ED should stop.
(iii) Noise and interruptions should be minimized by provision of adequate security and provider
assistants, while allowing for maintenance of situational awareness. During high-risk procedures,
providers must be allowed to focus on the procedure without interruptions or distractions. (iv)
ED systems for teamwork and handoffs as well as guidelines for procedures and checklists
should be developed, implemented, and evaluated for effectiveness and cost. (v) Information
systems can provide valuable patient-specific data as well as reference materials, and provide
assistance with follow-up. However, such tools as computerized physician order entry have not
been evaluated to clarify the benefits and costs of the various systems and should be adopted
with caution.
Conclusions
ED safety requires a multi-faceted approach that addresses provider knowledge, experience, and
cognitive errors; unique patient population characteristics; and the systems or environment of
care. Each specific area can be improved, but at a cost. Additional providers, training, and nurses
all cost money. Checklists and formalized handoffs may slow the flow and productivity of the
ED and ultimately reduce revenue. In light of this, each safety initiative must be analyzed based
upon cost, benefit, unintended consequences, and current risks within the system. Today's safety
efforts are focused on specific disease performance measures such as myocardial infarction (time
to cardiac catheterization laboratory) or pneumonia measures (time to antibiotics). These efforts
may improve care for some patients but may worsen care for other patients who are not
measured. There may also be unintended consequences of poorly designed measures, as
described by Wachter and colleagues. Only an integrated approach that addresses the
characteristics of providers, patients, and the overall system of care and that takes system
performance and well-designed specific disease performance measures into account will bring
about the needed improvements in ED safety