Profiles in patient safety: A "perfect storm" in the emergency department

Acad Emerg Med. 2007 Aug;14(8):743-9. doi: 10.1197/j.aem.2007.04.011. Epub 2007 May 30.


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.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Atrial Fibrillation / diagnosis*
  • Atrial Fibrillation / therapy
  • Attitude of Health Personnel*
  • Decision Making
  • Diagnostic Errors / prevention & control*
  • Diagnostic Errors / statistics & numerical data
  • Emergency Medicine / methods
  • Emergency Service, Hospital*
  • Emergency Treatment
  • Female
  • Humans
  • Interprofessional Relations
  • Kidney Failure, Chronic / diagnosis
  • Kidney Failure, Chronic / therapy
  • Middle Aged
  • Patient Transfer
  • Practice Patterns, Physicians'
  • Renal Dialysis / adverse effects
  • Renal Dialysis / methods
  • Risk Assessment
  • Safety Management*
  • Seizures / diagnosis*
  • Seizures / therapy