Background: Discrimination in hospital emergency departments (EDs) undermines health equity, patient trust, and the quality of care. Although its global prevalence is well recognized, little is known about the deeper systemic, structural, and cultural forces fueling discrimination within Iran’s healthcare system. This study aimed to illuminate the hidden dimensions and mechanisms of discrimination in ED services, providing insights to inform meaningful policy and practice reforms.
Methods: A qualitative study using thematic content analysis was conducted from December 2024 to July 2025. Participants represented diverse stakeholder groups involved in emergency care, including patients, family members, and healthcare professionals. Participants were recruited through purposive sampling with maximum variation. Data were collected through in-depth, semi-structured interviews lasting 25–60 min, totaling over 12 h. Interviews were audio-recorded, transcribed verbatim, and analyzed with Braun and Clarke’s six-phase framework using MAXQDA 2022. Study rigor was ensured through the application of Lincoln and Guba’s trustworthiness criteria, alongside reflexive practices to minimize researcher bias.
Results: Twenty participants took part in the study, including 12 ED patients, their family members, and eight healthcare professionals. Analysis produced six main categories and 24 subcategories: (1) non-transparent, bias-driven prioritization; (2) power asymmetry in staff–patient interactions; (3) reproduction of discrimination due to dysfunctional organizational structures; (4) misalignment between patients’ experiences and clinical templates; (5) discriminatory attitudes embedded in contextual culture; and (6) conflict between care ethics and institutional rules.
Conclusions: This study shows that discrimination in EDs is not just the result of individual bias, but a systemic issue shaped by organizational shortcomings, cultural attitudes, and power imbalances in staff–patient interactions. These patterns erode trust, compromise humane care, and leave many patients feeling marginalized. Addressing such inequities requires structural and cultural change that promotes transparency, empathy, and patient-centered values in emergency care.
Trial registration: Not applicable.
Supplementary Information: The online version contains supplementary material available at 10.1186/s12939-025-02685-y.
Keywords: Discrimination; Emergency department; Health equity; Iran; Patient experience; Qualitative research.