Thursday, October 17, 2013

A System for the System - System Errors in the ED

The Gist: In addition to cognitive biases, systems errors are ubiquitous in the emergency department (ED).  Free Open Access Medical education (FOAM) has inspired me to realize that one may mitigate some of these errors to improve patient care/outcomes by vigilance.

As a fan of metacognition, I attempt to mitigate my cognitive errors through simple practices. A few months into residency, I occasionally find myself frustrated by systems-based errors.  Finally, something to blame other than myself!  As that attitude is not terribly productive, I've adopted steps to attempt to overcome these errors, something I foresee as an evolving and expanding process.

Systems-based errors: reflect flaws or problems with process that are part and parcel of the health care delivery system.  These errors are often rooted in inefficiencies, issues with coordination of care, and communication [1].
Case #1:  A 54 y/o male presented to Janus General with fever to 38.8C, malaise, and weakness over the past 2 days. BP 126/82, HR 90. Patient had a PICC line to the right arm that appeared clean, status-post left hip wash out for septic arthritis 3 weeks prior.  I ordered labs and fluid, with plans for antibiotics.  Despite repeatedly checking for the lab results, they didn't appear.  Eventually, I called the lab - who reported receiving the specimens just minutes earlier as the hospital's tube delivery system had malfunctioned.  This resulted in another blood draw from the patient for a repeat lactate (which turned out to be 6), as the specimen was too old, a delay in more aggressive care, and a silly/guilty feeling doctor.  Studies demonstrate that delays in antibiotic administration impact mortality, so while the patient didn't appear to be in the sickest group of patients this still could have resulted in a bad outcome [2].  But, it's the system's fault, right?

Things I try to do to mitigate systems errors:
Communicate with nursing and support staff.  Oftentimes, they can help get things done more expeditiously or identify barriers to the proposed treatment plan.

Call the lab, radiology, pharmacy, etc.  Many steps exist between placing an order for a diagnostic evaluation or intervention and the completion of the order and an error can occur at any point. Furthermore, it's anecdotal, but I've been impressed with how face-to-face or verbal discussion of the "why" or need for urgency can expedite care.

Establish a consistent method to reassess patients/labs.  Time can fly in the ED and often our attention is divided by unexpected sick patients.  For example, we can handle a mostly stable GI bleeder, a septic patient, and a chest pain patient.  However, the minute one begins to crash or a code rolls in, our attention becomes divided and non-critical patients may be placed on the back-burner.  As a trainee, it's easy to think that a stable patient will remain stable but this isn't always the case.  Furthermore, interruptions are rampant in the ED and this forced shift in attention may lead to delays in reassessment [3].
  • Some keep running list of things in their pocket/workstation that need follow up.  A unique solution offered by Dr. Jeremy Faust - use Siri [4].  "Siri, remind me to re-examine room 4 in 30 minutes." 
Beware of alarm fatigue.  Alarms constantly ring in the ED and pop up in the EMR - but on occasion, they actually mean something.  It's important to catch it when it does.

Approach sign out with caution.  This area of emergency medicine has garnered much attention as it may lead to a hotbed of cognitive errors and the nature of sign-out can vary within the institution. Most of the literature revolves around the inpatient experience, but I think that the vulnerability of this process translates into the ED [5]. Physicians and hospitals approach sign out differently, but there's a call for increased standardization [6].  Consider standardizing your own approach.
  • Re-examine the patient, their vital signs, and crucial diagnostic/interventional endeavors.  
  • Tip from Dr. Jeremy Faust - start sign-out saying something along the lines of: I'm intentionally going to be a bit annoying, don't take it personally.  Then, aggressively go through the case. Two heads are better than one. 
Reexamine information received from outside physicians/transferring facilities.  Information often gets left out or lost in the series of communications surrounding transfers in care or partial work ups - minimize this by utilizing the patient's data.
  • Take a gander at a patient's EKG or diagnostics for yourself.  The "sinus bradycardia" for suspected accidental beta-blocker overdose may actually be a high degree AV block or a radiograph may be revealing.  
Establish a consistent method of follow up.  A myth exists that emergency physicians do not or should not follow up their patients.  As a result of the discontinuity of care, we will not typically see our mistakes unless we look for them. Check out the EM Res podcast on this topic.
  • In the EMR, I keep a list, by month, of patients I see in the ED so I can easily check up on patients.  This takes 1 extra click per patient but saves time attempting to recollect the name and has created the expectation within myself that I will follow up on some of those patients.
  • Consider a "bounceback" program.  This provides larger buy-in, but provides an invaluable educational opportunity.  At my institution, if a patient returns within 7 days, we receive a notification.  Oftentimes these are unpreventable (the daily drunk patient) or an indication that we provided good discharge instructions; however, more often than not there's a pearl for the future.
Use the EMR or family members to get to know the patient.  In the ED we don't know (most of) our patients, which can create fragmented care and an incomplete picture of our patient.  Valuable information can be found in the EMR (ex: the patient does, in fact, have baseline confusion and left sided weakness) or from family members who may be able to explicitly detail how the patient is different from baseline.

Case #2 (months later): A 51 y/o female presented to Janus General with cough, tachypnea, decreased oral intake.  Temperature 37.6C, BP 106/78, HR 136. Physical exam significant for tachypnea, rhonci in bilateral lung fields, and dry mucosa.  I discussed the plan with the nurse, emphasizing the patient's need for fluids and aggressive care.  The patient had no access and prior unsuccessful attempts, so the nurse quickly identified the need for ultrasound guidance.  Siri reminded me to check on the antibiotics and reassess the vital signs while suturing another patient.  The patient's vital signs, lactate, and clinical appearance normalized in the ED after several liters of fluid and the patient went on to do well.

Are there problems with attempted fixes for systems errors?
  • Improvements will fade as time passes secondary to decreased awareness, other foci of improvement, and lessened enthusiasm [1]
  • Fixes may produce opportunities for more errors
1. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what’s the goal? Acad. Med. 2002;77(10):981–92. Available at:
2.  Gaieski DF, Mikkelsen ME, Band RA,et al.  Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency departmentCrit Care Med. 2010 Apr;38(4):1045-53.
3. Elson, Ordell. Emergency Department Workplace Interruptions: Are Emergency Physicians “‘Interrupt-driven’” and “‘Multitasking’”? Academic Emergency Medicine 2000;7(11):1239–1243.
4.  Faust, JS. "The 'Sultan of Signout'" ACEP News. August 2013. p 12-13.
5. Arora V, Johnson J, Lovinger D et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysisQual Saf Health Care. 2005 December; 14(6): 401–407.
6.  Dhingra KR, Elms A, Hobgood C. Reducing error in the emergency department: a call for standardization of the sign-out process. Ann Emerg Med. 2010 Dec;56(6):637-42.


  1. Fantastic post, Lauren. Systems errors definitely abound, and even with communications with nursing/ staff, things can fall behind. Sometimes the tube system is down or what you communicate simply doesn't filter through for whatever reason. One thing that is always good to do, but especially when you feel like these errors are happening, is documenting re-exams and pt progress dutifully (and non-critically). It's a good habit that I suspect you already do, not only from a med-mal perspective (although, still a good reason), but from an Inpt. Perspective. When the MICU is wondering why abx were not started or why vitals are not in the computer for 3 hours, your documented re-exam can really help them out in terms of them seeing the ED trajectory etc. ah, medicine.

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