Evidence map›Paper›PMID 40033164›Full record

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.

Meagan M Ladell, Nancy L Jacobson, Sarah C Yale, Katie L McDermott, Elizabeth L Papautsky, Kenneth R Catchpole, Matthew C Scanlon

Abstract read
In one paragraph

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.

0numbers the graph read from it
0cells of the map it votes in
3citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

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.

2 · The registry

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.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

3 citing papers in PubMed.

  1. Review
  2. Review
  3. 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 · 2025
    Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

7 authors.

Meagan M LadellMedical College of Wisconsin, Milwaukee, Wisconsin, USA.ORCID 0000-0002-2513-4684
Nancy L JacobsonMedical College of Wisconsin, Milwaukee, Wisconsin, USA.ORCID 0000-0003-4242-7216
Sarah C YaleMedical College of Wisconsin, Milwaukee, Wisconsin, USA.ORCID 0000-0002-2954-4808
Katie L McDermottMedical College of Wisconsin, Milwaukee, Wisconsin, USA.ORCID 0000-0003-1740-387X
Elizabeth L PapautskyUniversity of Illinois-Chicago, Chicago, Illinois, USA.ORCID 0000-0003-2771-9579
Kenneth R CatchpoleMedical University of South Carolina, Charleston, South Carolina, USA.ORCID 0000-0003-4073-3025
Matthew C ScanlonMedical College of Wisconsin, Milwaukee, Wisconsin, USA.ORCID 0000-0003-2469-8020

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

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.

Indexed as

Diagnostic ErrorsEmergency MedicineMedical ErrorsPatient SafetyHumansRoot Cause Analysis

Identifiers

PMID40033164
PMCPMC11921065

What OpenQuestion holds

Textmetadata
LicenceCC BY-NC-ND
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Registered trials

None linked

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.