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Acad Emerg Med. 2011 Dec;18(12):1246-54. doi: 10.1111/j.1553-2712.2011.01231.x.

Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the emergency department.

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  • 1Brandeis International Business School, Waltham, MA, USA.


This article presents a model of how a build-up of interruptions can shift the dynamics of the emergency department (ED) from an adaptive, self-regulating system into a fragile, crisis-prone one. Drawing on case studies of organizational disasters and insights from the theory of high-reliability organizations, the authors use computer simulations to show how the accumulation of small interruptions could have disproportionately large effects in the ED. In the face of a mounting workload created by interruptions, EDs, like other organizational systems, have tipping points, thresholds beyond which a vicious cycle can lead rather quickly to the collapse of normal operating routines and in the extreme to a crisis of organizational paralysis. The authors discuss some possible implications for emergency medicine, emphasizing the potential threat from routine, non-novel demands on EDs and raising the concern that EDs are operating closer to the precipitous edge of crisis as ED crowding exacerbates the problem.

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