Abstract. The level of commitment in the analysis of clinical errors made in the emergency department (ED) is currently focused on organization and processes rather than on individual action. Four major cases of clinical errors made in the ED of a teaching hospital were investigated. Analysis suggested that the process of clinical decision making and the overreliance on the use of patterns during the cognitive process had a major role in causing the errors, rather than factors related to procedures or organization. It appears hard to design system changes and tactics to significantly reduce the probability of making errors associated with the cognitive process involved in clinical decision making. The authors have initiated a systematic analysis of errors made during the diagnostic workup in their ED, and the rate of clinically significant errors is tracked. A file is being created with the purpose to use it for teaching and orientation of all new staff. Key words: error; emergency medicine; procedures; cognitive process. ACADEMIC EMERGENCY MEDICINE 2000; 7:1278-1281 T HE DEBATE about clinical errors and the best way to analyze errors and to minimize their impact on adverse outcomes is increasing, even in the field of emergency medicine (EM). The level of commitment is currently focused on organizational systems and processes rather than on individual actions.1,2 The use of formal protocols and guidelines for diagnosis and treatment appears to ensure a systematic, comprehensive, and efficient approach to the process of clinical decision making, reducing to a minimum the probability of errors.We investigated whether major cases of clinical errors occurred at the emergency department (ED) of our teaching hospital during a one-year period. Cases were identified through reviewing the charts of patients who died in the ED or who were transferred to the intensive care unit (ICU) within 24 hours of their admission to the ED. Errors were defined as actions or missed actions that would have resulted in a change in the patient's care, actions that caused harm or death to the patient, or actions with the potential to do so. The goal of our investigation was to test the hypothesis that sub-
CASE REPORTSStudy Setting. The ED of San Camillo Hospital, Rome, Italy, is a high-specialty-level department with units of EM, emergency and trauma surgery, intensive care, neurosurgery, and heart surgery. The institution of a stroke unit and a chest pain unit is planned. A mean of 110,000 people are seen each year at our department.Residents training in endocrinology, internal medicine, EM, general and emergency surgery, anesthesiology, and intensive care work in our hospital and, specifically, in the ED. Courses of basic life support (BLS) and advanced cardiac life support (ACLS) are offered on behalf of the Italian Resuscitation Council.Case Finding. For purpose of this study, cases were identified using very restrictive criteria. Members of the staff carefully reviewed the charts of all patients who died in the ED or who were transf...