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“One definition of insanity is doing the same thing, over and over again, but expecting different results.”

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Rita Mae Brown, Sudden Death, 1983

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Patient safety tops everyone's list of priorities. Every participant in healthcare, patient and healthcare professional alike, wants a safe and error-free environment for patients that maximizes quality patient care outcomes. This desire has always been front and center for physicians and nurses; in the past decade hospitals and healthcare professionals have focused even more purposefully on safety. Through extensive research in various fields as well as in healthcare, healthcare professionals have come to realize that keeping patients safe is a complex endeavor that affects not only the quality of the care provided, but the satisfaction of patients with that care and the morale of the people who work in emergency departments (EDs). A safer ED is a better place both for patients and healthcare workers.

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To achieve a safe and reliable ED requires a particular mind-set: the intention to create a culture of safety. Doing so requires establishing an environment in which the emphasis is on how and why errors occur and what hospitals can do to head them off. This is richly illustrated in the results of a study over a 10-year period of cases in EDs that led to malpractice suits, in which the authors concluded that 80% of the errors in those cases could have been prevented.1 Even allowing for an element of confirmation bias on the part of study authors, the possibility of and the opportunity for reducing or preventing errors in the ED by 50% or more is a prospect that should have people in the field jumping excitedly out of bed in the morning. A quality department, a safe department, a high-reliability department is everybody's goal and this chapter (and Chapter 68) will highlight ways to prevent, mitigate, and eliminate errors, advancing a culture of safety in the ED.

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Creating a Culture of Safety

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The key to developing a culture of safety is to focus on processes, people, and performances that ensure a high-reliability department—an essential prerequisite for a safe environment. When operational reliability is attained, the number of errors is reduced—many are prevented from occurring—and the effects of errors that do happen can be mitigated. EDs that aim to achieve high quality in their patients' experience and outcomes place a continuous emphasis on the reliability of their process(s). The initial focus should be on developing and maintaining reliable processes, linked to clinical and service outcomes by evidence-based medicine and practices. Those EDs typically providing reliable quality focus on both what goes right and what could go wrong.

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As the Risser study implied, many errors that happen are preventable.1 Continually examining what happens every day or every week in the ED provides the data needed to identify what might happen to cause ...

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