ArticleAcademic emergency medicine : official journal of the Society for Academic Emergency Medicine2025
The problem with how we view medical (and diagnostic) error in emergency medicine.
Article in Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
3 citing papers in PubMed.
- Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors.Diagnostics (Basel, Switzerland) · 2026Review
- Integrating safety culture, environment, and sensory perceptions in the operating room: a narrative review.Langenbeck's archives of surgery · 2025Review
- The problem with how we view medical (and diagnostic) error in emergency medicine.Academic emergency medicine : official journal of the Society for Academic Emergency Medicine · 2025Article
Corrections and comments
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Authors and funding
7 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
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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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.