The Problem with How We View Medical (and Diagnostic) Error in Emergency Medicine
Open accessAbstract
Investigating error in healthcare has long been a central focus of patient safety efforts, yet this approach oversimplifies the complexities of a deeply interconnected and dynamic system. This paper argues that framing patient harm solely as "error" has failed to yield meaningful improvements, as it overlooks the broader factors contributing to adverse outcomes. Through a case study, we illustrate how an exclusive focus on error investigation missed critical insights and propose that attention should instead be directed towards identifying and managing hazards. Emphasizing the importance of treating healthcare as a sociotechnical system, we argue for the application of sociotechnical system thinking, particularly in addressing diagnostic errors in high-pressure environments like emergency medicine. The traditional methods, such as root cause analysis, error investigation, and the Swiss cheese model, are no longer sufficient. These outdated frameworks fail to address the systemic challenges clinicians face and often misguide safety interventions. The paper calls for a paradigm shift towards re-designing healthcare systems using human factors research to better align with the complexities of clinical work and the hazards that lead to harm.
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This fragmentation makes it challenging to understand how clinical, organizational, technological, and environmental factors collectively shape the complete picture of diagnosis.
“This fragmentation makes it challenging to understand how clinical, organizational, technological, and environmental factors collectively shape the complete picture of diagnosis [34].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [34]
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- Authors
- Ladell, M. M., Jacobson, N. L., Yale, S. C., McDermott, K. L., Papautsky, E. L., Catchpole, K. R., & Scanlon, M. C.
- Affiliations
- Medical College of Wisconsin (US)
- University of Illinois Chicago (US)
- Medical University of South Carolina Charleston South Carolina USA
- Corresponding author
- Ladell, Meagan M.
- ORCID
- Venue
- Academic Emergency Medicine
- Publisher
- Wiley
- Published
- 2025-03
- Volume
- 32
- Issue
- 3
- Pages
- 340-347
- ISSN
- 1069-6563 (ISSN-L)
- 1553-2712
- PMC
- PMC11921065
- OpenAlex
- W4408162122
- Cited by
- 8
- References
- 33
- Citations by year
- 2026: 4 · 2025: 4
- FWCI
- 10.39
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Academic Emergency Medicine (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Keywords
- medical errors, diagnostic errors, patient safety, emergency medicine, socio-technical systems, hazard identification, root cause analysis, Swiss cheese model, human factors, health system redesign, adverse events, error investigation
- MeSH terms
- Diagnostic Errors, Emergency Medicine, Humans, Medical Errors, Root Cause Analysis, Patient Safety
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