Learning from Accident and Error: Avoiding the Hazards of Workload, Stress, and Routine Interruptions in the Emergency Department

Major disasters are of interest to the emergency medicine (EM) community because they generate demand for EM services, but disaster and crisis may be of interest to EM for another reason: lessons from the study of disasters and crisis may be useful to the organization and practice of EM. Studies in the organizational theory literature examining the phenomenon of disasters, crises, and accidents, drawing on rich case studies and in-depth analysis,1–5 have yielded three significant insights that suggest there may be important parallels in EM. First, major disasters often do not have proportionately large causes. Rather, minor, everyday events can lead to major disasters, what Perrow calls “normal accidents.”5 Second, the likelihood of triggering chain reactions and a cascade of malfunctions and breakdowns greatly increases as the delivery system becomes increasingly sophisticated and interconnected with other systems. Such cascades lead to disproportionate and occasionally disastrous effects. Third, interruptions to ongoing activities or plans are associated with or implicated in the evolution of crisis.2,3,5–8 In particular, Rudolph and Repenning7 establish how the sheer quantity of interruptions to established routines and expectations plays a significant role in precipitating disasters. Emergency departments (EDs) are sophisticated and interconnected with other systems. ED crowding and overcrowding, major challenges to the field that continue despite years of efforts to address the problem,9–12 are likely getting worse.13,14 Crowding occasions tighter coupling of the systems5 and will likely make sophistication and interconnectedness even more salient features of the ED. EDs have also been characterized as “interrupt-driven.”15 Several studies have reported that emergency physicians (EPs) are interrupted an average of approximately 10 times per hour,15–17 and nurses are interrupted even more often.16 Interruptions contribute to medical error18 and have been implicated in increasing stress and reducing efficiency among physicians.19 However, the role of interruptions in precipitating organizational crises in the ED has not been explored. While it is tempting to invoke proportional logic—the more interruptions there are, the worse things get—the dynamics of tightly coupled systems are more complex than this simple proportional logic would suggest.2,3,5,7,8 To understand the dynamic interplay among quantities of small events, we present a theory that takes into account the state of the environment surrounding the ED, the ED’s capacity to respond, and the manner in which the system adjusts to cope with varying demand. The approach will be to draw on simulation and analysis of a system dynamics model, developed by Rudolph and Repenning7 to understand the dynamics of disasters, that examines the interconnections between the quantity of small events and organizational crises. We begin with a description of some case studies of disasters, then present the model and analyses, and conclude with a discussion of some implications for EM.