Clinical errors in emergency medicine: Experience at the emergency department of an Italian teaching hospital

The level of commitment in the analysis of clinical errors made in the emer gency department (ED) is currently focused on organization and processes ra ther than on individual action. Four major cases of clinical errors made in the ED of a teaching hospital were investigated. Analysis suggested that t he process of clinical decision making and the over-reliance on the use of patterns during the cognitive process had a major role in causing the error s, rather than factors related to procedures or organization. It appears ha rd to design system changes and tactics to significantly reduce the probabi lity of making errors associated with the cognitive process involved in cli nical decision making. The authors have initiated a systematic analysis of errors made during the diagnostic workup in their ED, and the rate of clini cally significant errors is tracked. A file is being created with the purpo se to use it for teaching and orientation of all new staff.