HiQuiPs: Patient Safety in the ED Part 1 – Introduction to the Systems Approach

In Education & Quality Improvement, HiQuiPs by Ryan TamLeave a Comment

So far in our series we’ve explored several approaches, frameworks and tools that will help guide you through the process of quality improvement. You are probably eager to get started at this point (or you may have already!), but you may be wondering which areas to target first in your emergency department (ED). In a previous post we listed some high-yield priorities to choose from. Among these, one of the most recognized and accessible domains to improve care is patient safety.

It is our hope that these posts will interest the casual clinician or empower the physician lead who wants some broad concepts and pragmatic tools to bring to their next patient safety meeting. For those looking for a different depth of knowledge we encourage you to visit CAEP’s QIPS resource which lists a variety of quality improvement and patient safety educational programs from beginner to advanced.

Patient safety first gained national press after the release of the report “To Err is Human” by the Institute of Medicine (IOM) in 1993.1 It was the first national report to attempt to quantify medical errors during hospitalizations in the United States. The estimated 98,000 medical errors per year in the U.S. was more than breast cancer, motor vehicle accidents and AIDS combined at that time. This galvanized the U.S. government, the healthcare industry and the public to work towards major reforms to improve these figures. By 2002, the World Health Organization recognized that medical errors were a pervasive problem in how we delivered healthcare globally.2 Moreover, it was last estimated that 185,000 adverse events leading to death, disability or prolonged stay occurred in our Canadian hospitals in 2004.3

To err is human cartoon

Amongst the central guiding principles that came out of the IOM report and the subsequent patient safety movement was the paradigm shift from a persons-based approach to a systems-based framework for understanding the underlying causes of medical errors. Below is a summary of the seminal paper by James Reason on the two approaches to human medical errors:4

  1. The persons-based approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness
  2. The systems-based approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects
  3. We cannot change the human condition [i.e. the propensity to commit medical error], but we can change the conditions under which humans work
  4. Blaming individuals is emotionally more satisfying than targeting institutions

It is worth noting that these are just guiding principles, which are not necessarily intuitive for healthcare providers to accept. We have been trained and nurtured in a medical culture that expects nothing short of perfection. We find comfort in believing that only we, alone, are immune to human errors. We also firmly believe that when errors are made it is because the individual was careless or less skilled than us, and given the exact same circumstances, we would have succeeded.5 This is a fallacy! This is also the most important cognitive leap to make, from focusing on the individual to focusing on the system that the individual is part of.

Healthcare was not the first industry to go through this safety renaissance. Nuclear power plants, air traffic control centres and aircraft carriers have all been observed to operate using a similar systems-based approach and have successfully reduced errors and improved outcomes over time.6

Companies in the aforementioned industries are aptly named High Reliability Organizations because they reliably complete very complex tasks under significant time pressures at extraordinary low incidences of errors.7 Their formula for success is commonly characterized by:

  • Preoccupation with Failure: everyone is always looking for potentials for failure in the system
  • Reluctance to Simplify: everyone understands that their work is complex and dynamic and seek underlying, rather than surface, explanations
  • Sensitivity to Operations: everyone has situational awareness of their role in the organization
  • Deference to Expertise: those closest to the work are the most knowledgeable about the work
  • Commitment to Resilience: workers are mentally ready to respond when unpredicted system failures occur

How can this systems-based approach to patient safety be applied to your ED? The first step is to identify and track underlying system factors that affect your department. Some commonly targeted system factors more amenable to change include: teamwork and communication (patient safety culture), the physical and digital environment (ergonomics, human factors, health informatics), and integration of the ED with the hospital (performance tracking). A more exhaustive list can be found on the CPSI website.8 Find an area you are passionate about and start there!

Patient safety may still be a distant concept discussed primarily in your department hallways but rest assure you are likely indirectly already part of a healthcare network that has adopted this model of care!9 Join us next month as we dive deeper, gain a better understanding of patient safety related concepts, and discuss a novel way of approaching patient safety in your department.

Key Points:

  1. The ED is a complex system that is inherently prone to medical error
  2. Traditional healthcare culture biases us towards a persons-based approach to medical error and patient safety
  3. A systems-based approach to reducing errors and targeting system factors can transform healthcare organizations into high reliability organizations

This post was copyedited by Paula Sneath

Click here for more articles in the HiQuiPs series!

**UPDATE (November 2020): The HiQuiPs Team is looking for your feedback! Please take 1 minute to answer these three questions – we appreciate the support!**


Institute of, Kohn L, Corrigan J, Donaldson M. To Err is Human: Building a Safer Health System. January 2000. [PubMed]
Quality of Care: Patient Safety. Fifty-Fifth World Health Assembly. http://www.who.int/patientsafety/worldalliance/ea5513.pdf. Published March 23, 2002. Accessed February 3, 2019.
Baker G, Norton P, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-1686. [PubMed]
Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. [PubMed]
Reason J, Carthey J, de L. Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management. Qual Health Care. 2001;10(Suppl 2):ii21-ii25. [PMC]
Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open. 2015;7(1):2054270415616548. [PubMed]
High Reliability | AHRQ Patient Safety Network. Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/primers/primer/31/high-reliability. Published January 2019. Accessed October 1, 2018.
Rich P. High Reliability Organizations Finding a Home in Canada. HealthCareCAN . http://www.healthcarecan.ca/2015/03/01/high-reliability-organizations-finding-a-home-in-canada/. Accessed October 1, 2018.

Ryan Tam

Dr. Ryan Tam is an emergency physician at Trillium Health Partners with a focus on Quality Improvement, Health Informatics, and Health Care Systems Design.
- 4 years ago

Amy Cheng

Dr. Amy Cheng is an emergency physician at St. Michael’s Hospital (SMH) at the University of Toronto. She obtained an MBA with a focus on social entrepreneurship. She is passionate about improving the quality of patient care and safety, and currently serves as the ED Director of Quality Improvement at SMH, and was the Medical Director for Quality Improvement and Patient Safety for SMH. She led the development of the top 10 Choosing Wisely Canada recommendations for emergency medicine as the co-chair of the Canadian Association of Emergency Physician (CAEP) Choosing Wisely Canada working group.

Ahmed Taher

Ahmed is an Emergency Physician at University Health Network and Mackenzie Health in Toronto. He completed the Toronto FRCPC Emergency program, and a Masters of Public Health program at Johns Hopkins Bloomberg School of Public Health with certificates in Quality Improvement & Patient Safety, as well as Public Health Informatics.
- 4 months ago

Lucas Chartier

Dr. Lucas Chartier is an emergency physician and Deputy Medical Director for the University Health Network (UHN) emergency department (ED). He is also UHN's inaugural Medical Director of Quality and Safety, the ED Lead for the Toronto Central Local Health Integration Network (TC LHIN) and the Chair of the Quality Improvement and Patient Safety (QIPS) Committee of the Canadian Association of Emergency Physicians. With training at McGill (MD CM), University of Toronto (FRCPC) and Harvard (MPH), he now tries to spread the QIPS gospel in all the ways possible!