Full text of DOI:10.1111/j.1553-2712.2000.tb00464.x

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PROCEEDINGS
Croskerry et al. • EDUCATIONAL AGENDA
Setting the Educational Agenda and Curriculum for
Error Prevention in Emergency Medicine
PAT
C
ROSKERRY, MD, P
HD, ROBERT L. WEARS, MD, MS,
LOUIS S. BINDER, MD
Abstract. Graduate and postgraduate medical ed- will work in emergency department settings, and
ucation currently teaches safety in patient care by pass on those insights and innovations. The specifics
instilling a deep sense of personal responsibility in of what should be taught are outlined briefly. Work is
student practitioners. To increase safety, medical ed- currently ongoing to identify more specifically the
ucation will have to begin to introduce new concepts core content that should be included in educational
from the ‘‘safety sciences,’’ without losing the advan- programs on patient safety in emergency care. Fi-
tages that the values of commitment and responsi- nally, careful attention will have to be paid to the way
bility have gained. There are two related educational in which these principles are taught. It seems un-
goals. First, we in emergency medicine (EM) must de- likely that a series of readings and didactic lectures
velop a group of safety-educated practitioners who alone will be effective. The analysis of meaningful
can understand and implement safe practice inno- cases, perhaps supplemented by high-fidelity simu-
vations in their clinical settings, and will be instru- lation, seems to hold promise for more successful ed-
mental in changing our professional culture. Second, ucation in patient safety. Key words: education;
EM must develop a group of teachers and researchers safety; errors; emergency medicine; curriculum. AC-
who can begin to deeply understand how safety is ADEMIC EMERGENCY MEDICINE 2000; 7:1194–
maintained in emergency care, develop solutions that 1200
HE ACQUISITION of medical knowledge is titioners and researchers. At the outset we need to
incremental. It is a process of gradually ask several questions: 1) Who should be educated?
T
building on a framework established according to
the scientific method and the epistemological ten-
ets of the discipline.1 New quanta of information
are accepted and added to existing dogma. Para-
doxically, perhaps the greatest discovery in the last
decade of the last millennium was not of new data,
but of a latent phenomenon already embedded
within clinical practice, medical error. From this
discovery, a new and critically important discipline
has emerged—the science of error prevention in
health care.2
Any new field, at its beginning, has numerous
problems of scope, methods, theories, and defini-
tions. One of the most important problems this
field faces is how to transfer newly-gained knowl-
edge and information to current and future prac-
2) What should be taught? 3) How should it be
taught? 4) Who should teach it?
The significant change in our professional cul-
ture that is needed can be advanced through lon-
gitudinal educational initiatives. We acknowledge
that the design of effective teaching methods and
curricula will be an iterative process that will
evolve as the science develops and through feed-
back from those whom we teach.
1. Who should be educated? The formal ped-
agogical approach is to include all those in training
within the educational system, i.e., students of
medicine, nursing, pharmacy, social work, para-
medicine, and other allied fields. This constitutes
the first educational sphere (Fig. 1).
However, the educational mandate extends be-
Department of Emergency Medicine, Dalhousie University,
Queen Elizabeth II Health Sciences Centre, Halifax, Nova Sco- yond the classroom and the floor of the emergency
tia, and Department of Emergency Medicine, Dartmouth Gen-
eral Hospital, Dartmouth, Nova Scotia, Canada (PC); Depart-
ment of Emergency Medicine, University of Florida,
Jacksonville, FL (RLW); and Department of Emergency Medi-
department (ED). One of the greatest hurdles will
likely be the education of our colleagues in current
practice. It is one thing to introduce a new way of
thinking to those in training; they are a captive
audience and will readily pick up the attitudes and
customs we teach and adopt ourselves. But it is
quite another to change the attitudes and belief
systems of those currently in practice in whom
habits are well entrenched. Old dogs take longer
to learn new tricks. Considerable effort will be re-
cine, Case Western Reserve University, MetroHealth Medical
Center, Cleveland, OH (LSB).
Received July 22, 2000; accepted July 28, 2000.
Address for correspondence and reprints: Pat Croskerry, MD,
PhD, Department of Emergency Medicine, Dartmouth General
Hospital, 325 Pleasant Street, Dartmouth, Nova Scotia, Can-
ada, B2Y 4G8. Fax: 902-465-8579; e-mail: dghosp@crhb.ns.ca
or xkerry@accesscable.net

ACADEMIC EMERGENCY MEDICINE • November 2000, Volume 7, Number 11
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quired to socialize existing faculty into the new ships and collaboration in minimizing error.
culture of medical error reduction. The level of con- However, an overtolerance of error might lead to
sciousness must be raised and techniques for at- complacency and inertia. We must make clear to
titude change must be explored to ensure wide- the public our fundamental, sustained, and serious
spread acceptance of the need to study, monitor, commitment to systematic change to make things
and report medical errors.
better. We should be careful, too, that focusing the
The second educational sphere will also include public’s attention on medical malfeasance does not
blunt-end personnel, the administrators, manag- lead to a greater insecurity and wariness in the
ers, and supervisors. All will need a basic ground- public.2 If we seriously undermine the healers, we
ing in general error theory, and in the science of reduce their power to heal.
medical error in particular. Only then can we begin
It is especially important that we direct edu-
to address some of the challenges in creating in- cational efforts at the legal system. The current
stitutional changes in systems and practices. Cur- atmosphere and structure of malpractice litigation
rent reporting systems grossly underestimate the are major impediments to cultural change.2,5 An ef-
base rate of error,3 and those concerned with risk fective reporting system will be crucial to the sci-
management and continuous quality improvement ence of medical error, yet, an honest and full dis-
(CQI) programs will need to re-examine their closure of errors from health professionals is
methods and procedures for collecting meaningful unlikely unless we can achieve liability reform in
and useful data. We should not underestimate the a legal system that currently ‘‘induces secrecy and
considerable institutional inertia against timely silence.’’2
and appropriate error management that currently
exists, and that presents a formidable obstacle to and the instrumentation that we use need to have
the development of a culture of safety. a good working knowledge of error theory. Not sur-
Clearly, too, those who design our work areas
It is clear, too, that other of society’s sectors prisingly, the interface between worker and work-
should be targeted by these educational efforts. place can be a significant source of error.6 The im-
The third sphere includes those not directly in- portance of human factors engineering (HFE) and
volved in the delivery of health care. An attitude safety in the training of health care personnel is
shift needs to occur in the general public so there emphasized in the Institute of Medicine (IOM) re-
are more realistic and sympathetic views of the port,7 and the American Nurses Association lists
health care system and its inherent fallibility. It is HFE as one of its seven areas of competence.8 Pro-
fairly easy to imagine, for example, what the cur- ponents of HFE make a good case that those re-
rent stance toward blaming might be in the British sponsible for medical software, instrumentation,
patient advocacy group Sufferers of Iatrogenic Ne- and work area design need feedback and direction
glect (SIN). A similar innuendo was conveyed in from clinicians and risk managers to guide ‘‘user-
the acronym for the Quality in Australian Health centered design’’ and reduce error.9–11 Good crafts-
Care Study (QAHCS) published in 1995.4 The no- people do not blame their tools, but they might
tion that errors are sins, or due to incompetence, make fewer errors with better tools.
is pervasive in society. A better general under-
The outermost educational sphere containing
standing of human and systemic error in the deliv- local and federal government agencies is a critical
ery of health care would make for better partner- focus. The state has an obligation to protect the
Figure 1. Four spheres of educational influence.

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Croskerry et al. • EDUCATIONAL AGENDA
T
ABLE 1. Curriculum
Core Session
Basic error theory (Table 2) All groups
ciplinary approach toward education in the health
professions.15 This important initiative aimed to
break down traditional territorial barriers and pro-
mote teamwork. We believe that the core program
should be shared and concurrently taught to the
various disciplines of medicine, pharmacy, nursing,
paramedicine, and allied fields. The historical ap-
proach to health care education has been that each
discipline develops and pursues its own curriculum
independently of the allied disciplines. This inevi-
tably produces fragmentation, with different
groups operating in isolation and occasionally in
opposition. In a study of closed claims in the ED,
teamwork failures were implicated in more than
40% of cases.16 In contrast, a multidisciplinary cur-
riculum would foster a team approach, cultivate
team distributed cognition,17 and lead to the break-
down of formal, horizontal and vertical divisions of
labor that may contribute to ED error.14,16,18 Such
an innovative multidisciplinary approach to teach-
ing the science of medical error, involving trainee
physicians, nurses, and pharmacists, was success-
fully initiated several years ago at Michigan State
University.6
Target Group
Team dynamics
Coping with error
Feedback
All groups
All groups
All groups
All groups
Communication
Procedural errors
Affective errors
Cognitive errors
Discipline-specific/some overlap
Patient contact groups
All groups
Human factors engineering
All groups
public, and government may feel obliged to take
regulatory action in any area where public safety
appears to be threatened. This precautionary prin-
ciple12 may generate a new set of problems and
errors, and lead to enforced regulations with atten-
dant penalties for violations. Thus, new innova-
tions and solutions may generate new hazards, es-
pecially when imposed from outside the system.
The present initiative is prudent, therefore, in that
by making our educational objectives clear we
might be allowed a greater say in the design and
function of the new system. This is preferable to
having one imposed upon us.
The core curriculum should also include edu-
cational initiatives directed toward the individual
response to error. Historically, physicians have
taken the major responsibility for adverse out-
2. What should be taught? The content will de- comes, both emotionally and legally. The individ-
pend upon which of the educational spheres is be- ual response has often been maladaptive, involving
ing targeted. For the purposes of the present dis- excessive self-recrimination and the use of inap-
cussion and the remainder of this paper, only the propriate and counterproductive defense mecha-
first sphere is considered. However, much of what nisms.19–22 While a better understanding and more
is proposed also applies to clinicians already in open discussion of error will go some way toward
practice. Different techniques and strategies will de-mystifying it, further insights might be gained
be required to effect change in each of the spheres. from faculty who have expertise in coping with and
The starting point of the educational curricu- minimizing the impact of medical error. With the
lum for those in training should be basic error the- more distributed responsibility that teamwork
ory (Table 1). One of the difficulties here is that brings, adverse outcomes will have a wider impact,
the area belongs to no discipline in particular, al- and these sessions should again be multidiscipli-
though the major developments have come from nary.
the behavioral sciences. Other significant contri-
Each discipline should identify meaningful pat-
butions have been made by engineering, the mili- terns in practice that indicate impending error. A
tary, and industry, notably aviation. It would be classic example in EM is our vulnerability to the
impractical and unreasonable to expect students to phenomenon of anchoring bias.23 This is the ten-
research this literature and develop a working dency to focus on early presenting features of ill-
knowledge of the diverse languages and terminol- ness, and may result in premature diagnostic clo-
ogies of the respective disciplines. Instead, emer- sure.24 The conclusions we reach depend on where
gency medicine (EM) educators should develop a we begin and what we allow as our starting points,
series of core sessions on error theory, with topics or anchors. However, once insight has developed
selected for their relevance and expressed in a lan- into cognitive biases and such patterns are known,
guage that is comprehensible to the target audi- students can be trained to recognize scenarios that
ence. A selected bibliography would be provided for carry a potential for a particular type of error. This
those interested in further and more advanced situational assessment approach is embodied in
study. A suggested list of core content topics is the ‘‘recognition-primed decision model’’ described
given in Table 2.
by Klein.25 Once the situation has been recognized,
In 1995, the Interdisciplinary Generalist Cur- cognitive forcing strategies may be used to abort
riculum Project was initiated to foster an interdis- the error.23

ACADEMIC EMERGENCY MEDICINE • November 2000, Volume 7, Number 11
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T
ABLE 2. Core Content Topics
The activities of all disciplines can be broken
down into three areas: procedural, affective, and
cognitive.24 Each discipline has a repertoire of pro-
cedural skills that is fairly specific, although some
overlap occurs. For example, intubation is largely
the province of paramedics and physicians,
whereas the administration of medication and is-
sues around drug interaction and compatibility are
more the domain of nurses and pharmacists. Each
discipline should address the potential sources of
error that might arise from its procedures and col-
laborate with other disciplines where appropriate.
Affective errors are made primarily by those
who interact with patients: nurses, physicians,
paramedics, and social workers. In part, they arise
from transference and attribution phenomena.23
Basic error theory
Classification and taxonomy of errors
Root cause analysis
Systems error/process measures/Swiss cheese theory13*
Cognitive psychology theory
Clinical decision making
Experience/acumen/sapiential authority14
Endogenous factors affecting performance (shiftwork, fatigue,
burnout)
Countermeasures/forcing functions/interlocks
Error identification and reporting strategies/continuous qual-
ity improvement
Preventability theory
Basic dynamics of teamwork
*For complete citations, see the reference list.
The extent to which actions and decisions in EM EM and the ED result in extraordinary deficiencies
are influenced by affective variables is very much in providing appropriate feedback to its personnel.
underappreciated. Currently, there is little core Patients are usually unknown to the nurses and
content in any of the health care disciplines that physicians, and there is little continuity of care.
draws attention to this covert and important The current practice of EM is almost diametrical
source of error.
to the provision of feedback.28 Complex cases are
By far the greatest proportion of our time in the left at the end of the shift to another team, and
ED is spent in cognitive activity.23 A number of cog- unless deliberate efforts are made to follow up, the
nitive biases and flaws have been described in the outcomes are never known. Many undiagnosed and
cognitive sciences literature.26 These appear to be interesting cases are referred to specialty services
universal and have been demonstrated in a variety and disappear forever into a void. Also, access is
of professional groups. We should expect that they being lost to the ultimate criterion standard of
would affect all disciplines, with the most vulner- feedback, the clinical autopsy. Despite the histori-
able groups being physicians, paramedics, and cally persistent 40% discordance between clinical
nurses. Several studies have attempted to correct diagnosis and that revealed at autopsy, the clinical
cognitive bias, with varying degrees of success.27
A
autopsy rate is declining significantly.29 Further,
major advantage of educating those who are in when an autopsy is performed, coroners and path-
training is that there will have been little rein- ologists do not routinely provide the results to the
forcement or entrenchment of at least some of attending emergency physician (EP).
these biases, so the training process can serve to
The overall problem is compounded further by
inoculate against developing them in the future. our unwillingness to provide direct feedback when
For practicing clinicians, some inertia will need to the outcome may reflect negatively on the clinical
be overcome in changing longstanding beliefs and management. Positive feedback is clearly impor-
behaviors, and the task will be correspondingly tant too, and often lacking. Health care providers
more difficult.
generally expect a high standard of themselves,
Another core feature should be the role of feed- but it is important occasionally to receive affir-
back. It is difficult to imagine any progress being mation of that. We learn through feedback. It is
made unless we can learn from errors. Learning to the critical feature in the acquisition of any pro-
drive a car would be extremely difficult without cedural, affective, or cognitive skill. Emergency
knowing the consequences of turning the steering medicine must teach the importance of feedback
wheel in the wrong direction, or applying the foot- and the implementation of specific strategies to op-
brake or gas pedal too hard. All of these actions, timize it. Everyone is in the feedback loop, includ-
as well as the more sophisticated ones, such as the ing the patient.
judgment of relative speed and distance in over-
Feedback is one component of the larger prob-
taking, are acquired through seeing the conse- lem of communication. Good communication skills
quences of our thoughts and actions. In the ab- are especially important in the ED, where critical
sence of feedback, we tend to assume that our information is being transmitted, often under time
performance is satisfactory. Importantly for this pressures. Despite the generally tight coupling of
discussion, we learn more from our mistakes than interdisciplinary relationships, problems in com-
from our successes. Errors are a rich source of munication can arise from the vertical and hori-
learning material.
zontal organization referred to earlier, as well as
However, the unique design and operation of discipline-specific language. Each discipline has id-

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T
ABLE 3. Teaching Techniques
of working toward the understanding or resolution
of a problem,’’31 and is considered more nurturing
and enjoyable than traditional methods.
Didactic sessions
Small-group/tutorials
Problem-based learning
Workshops
Narrative accounts/clinical cases/vignettes
Computer interactive/graphics
High-fidelity simulation
Apprenticeship/mentoring
Selected reading materials
Narrative accounts and clinical cases (war sto-
ries) have long been a feature of clinical teaching.
They may suffer from the typical problems asso-
ciated with anecdotal accounts such as selective
reminiscence, embellishment or exaggeration, fail-
ure to take account of ambient conditions, and lack
of statistical validity. Nevertheless, if these limi-
tations are recognized, they can serve as a vivid,
powerful tool for gaining the attention of trainees,
as well as practicing clinicians. This is reflected in
the observation that case reports are the most fre-
quently read sections of medical journals, and sup-
ports the naturalistic model of decision making
that domain expertise is acquired only through a
combination of experience and the relating and
repetition of meaningful stories.32,33 Thus, if the
session facilitator for PBL error training is an ex-
perienced clinician, this personal, experience-
based strategy would be a useful adjunct. In con-
trast to the passive role students play in didactic
sessions, PBL involves students actively and re-
sponsibly in the learning process. Workshops share
many of the features and advantages of small-
group learning. Through their less structured and
more open-ended format, they allow greater free-
dom of thought and creativity, and encourage nov-
elty in the search for solutions.
iosyncrasies of language, and operates with a dis-
tinct set of priorities. Effective teamwork needs
clear communication and common priorities, and
these should be an integral part of the educational
curriculum.
Finally, the curriculum will need an HFE com-
ponent.6 It is clear that information technologies
have the potential to significantly improve decision
making and reduce medical error. It should be rec-
ognized, too, that innovations can sometimes cre-
ate new sources of error.30 Health care profession-
als who use software and medical instrumentation
are the best source of feedback to the companies
who design them. Good feedback results in better
design and fewer errors.
After the core program has been completed, the
respective disciplines can take responsibility for
education in supplementary discipline-specific top-
ics, but these should not be exclusive of other dis-
ciplines. For example, there already exists a sub-
stantial literature on medication errors.7 This area
could be developed by pharmacy faculty and then
jointly presented to pharmacists, nurses, physi-
cians, and paramedics.
High-fidelity simulation is a powerful technique
and can work in several ways. It allows us now to
revise the maxim ‘‘see one, do one, and teach one.’’
Essentially, simulation includes all techniques
whereby the novice can mentally rehearse or ‘‘walk
through’’ a clinical problem ‘‘off line’’ without hav-
3. How should it be taught? It has become ing to experience the real problem personally. It is
abundantly clear over the last few decades that a way of gaining experience without experience.
there is more to teaching than the traditional di- For example, near virtual reality in procedural
dactic method. We now have a number of tech- tasks (e.g., intubation, ultrasound) can be achieved
niques that can make education more effective and using sophisticated inanimate models. The old
interesting (Table 3).
maxim should now become ‘‘see virtually many, do
Didactic sessions remain a useful basic tech- the real thing with much more competence and
nique for getting information across to large confidence, and direct the next student to the
groups efficiently in a short space of time, and will model.’’ A different kind of mental rehearsal for in-
form an integral part of most educational curric- tubation can be achieved through the technique of
ula. Presentations can be made more effective with using a microcamera to videotape the actual pro-
visual aids such as videos, graphics, and cartoons. cess for a variety of different intubations.34 This
Small groups/tutorials were pioneered in med- again allows thorough mental rehearsal before at-
ical education at McMaster University Medical tempting the real procedure.
School in the 1960s as the vehicle for its inno-
For cognitive problems, mental rehearsal
vative problem-based learning (PBL) program. through simulation can be achieved in several
Historically, the tutorial system had originated in ways. After a short didactic session in which a se-
the major English universities, Oxford and Cam- ries of cognitive biases and errors are described,
bridge. The majority of medical schools in North video records can be made of actors playing out
America now use tutorial-based PBL to foster self- scripts of clinical scenarios in which the same bi-
directed learning.31 Problem-based learning is de- ases and errors are demonstrated. Students can
fined as ‘‘the learning that results from the process analyze the tape repeatedly until all the errors

ACADEMIC EMERGENCY MEDICINE • November 2000, Volume 7, Number 11
1199
have been detected. Alternatively, after the didac- provide inventories of faculty expertise and inter-
tic session some students themselves can act out ests, and to facilitate curriculum reform as
the scripts to role-play the various errors, while needed.31 The primary teaching should probably be
their colleagues perform the analysis.
done by EPs, nurses, paramedics, or pharmacists
A further technique is to place students in a with a special interest, and specialized training, in
laboratory-simulated clinical situation with actors. the science of error reduction. Appropriate funding
An audio and video record is made of their behav- will be necessary for program development, as well
ior, clinical performance, and decision making. as protected teaching time.
Various distractions can be introduced to manipu-
A potential problem with multidisciplinary fac-
late the situational difficulty.35 The tape is later ulty is that significant difficulties might arise with
reviewed and systematically analyzed by the stu- language. Therefore, a major goal of the faculty
dents and instructor. This technique is not limited should be to ensure the development of a jargon-
to clinical topics, but can be used to enhance com- free and straightforward language of error, one
munication, prioritization, teamwork, and re- that is easily understood and readily communi-
source management skills in critical situations.
cated among the various disciplines of emergency
health care. Some core terms that originated in
4. Who should teach it? Just as the specialty other disciplines will need to be preserved and in-
of EM grew out of a public demand for improved troduced into the language of emergency person-
quality of medical care and expertise in the ‘‘emer- nel. However, it is also likely that the language
gency room,’’36 so too has the science of error pre- will incorporate new terms providing a lexicon
vention in health care grown from a public demand unique to the discipline of EM.23,39
for safe medical care. The foremost advocate of the
Emergency caregivers may have other roles to
public in this regard is the National Patient Safety play in the development of this new science by vir-
Foundation, established under the auspices of the tue of their work environment. Among the various
American Medical Association in 1997 and com- specialties, the highest level of clinical uncertainty
mitted to the improvement of patient safety in the exists in EM. If there were no uncertainty there
delivery of health care.
would be no need for decisions, and it is clearly the
At the inception of any new science, there will specialty with the highest decision density. Deci-
be no formally trained faculty to teach it. This sion-making processes inevitably involve error,
point was made clearly by Leape following his pre- which makes the ED a natural laboratory for the
sentation at the recent British Medical Association study of medical error in complex and uncertain
conference on medical error.37 Those who are cur- environments.40
rently interested in the science of error prevention
Emergency physicians provide a unique re-
in medicine, and who have brought it to its incep- source to health care systems. The nature of the
tion, are by definition its first teachers. They must work in EM requires emotional resilience, physical
provide the initial academic constructs that will stamina, intestinal fortitude, cognitive flexibility,
describe the field. This is in fact the purpose of this and other personal attributes. Emergency medi-
document. The establishment of training programs cine is the only specialty that requires its practi-
will further define it and lead to a second genera- tioners to remain current in, and regularly com-
tion of teachers and researchers who can carry on municate and interact with, each of the other
the work. As an immediate step, consideration specialties. Emergency personnel are probably the
should be given to developing a fellowship year for most eclectic of the various disciplines.
EM residents in the science of medical error re-
duction.
It has been proposed that hospitals set up pa-
tient safety boards and acquire cross-disciplinary
Much of the pioneer work in the field of error experts in HFE and in the science of medical error
came from diverse fields such as the behavioral sci- reduction.11 Such programs might benefit from the
ences, industry, and engineering. Medicine has coordination and guidance of a professional edu-
been a fairly late arrival, with anesthesia taking cator.31 From the foregoing it would appear that
the early initiative.38 We anticipate that future fac- residency-trained EPs, with a fellowship year in
ulty will be multidisciplinary, at least in a consul- the science of medical error and HFE, would be
tative capacity, and should include industrial and ideal candidates for these positions. Their work
cognitive psychologists, sociologists, specialists in portfolio might consist of serving as teaching fac-
human factors engineering and organizational be- ulty for medical error science, hospitalist work in
havior, and systems design/process analysts. The HFE and error reduction, and independent inves-
faculty should develop a specific curriculum and tigation of serious adverse events, as well as clin-
hold regular seminars and workshops to promote ical and research time in the ED.
and develop interdisciplinary communication and
We are responsible here for the initiation of the
relationships; listservs should be made available to educational process, but its fine tuning will require

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Croskerry et al. • EDUCATIONAL AGENDA
tional medical school demonstration project. Acad Med. 1995;
70(Jan suppl):S75–S80.
input from many others. The early educators have
one great advantage. They are guided by recent
memory of the development of EM as a speciality
science. It is only fitting that they are now in the
forefront of the development of error prevention in
EM as a special science and the educational pro-
cess through which to teach it.
16. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD,
Brens SD. The MedTeams Research Consortium. The potential
for improved teamwork to reduce medical errors in the emer-
gency department. Ann Emerg Med. 1999; 34:373–83.
17. Salomon G. No distribution without individuals’ cognition:
a dynamic interactional view. In: Salomon G (ed). Distributed
Cognition: Psychological and Educational Considerations.
Cambridge, MA: Cambridge University Press, 1993.
18. Patel VL, Cytryn KN, Shortcliffe EH, Safran C. The col-
laborative health care team: the role of individual and group
expertise. Paper presented at the American Medical Informat-
ics Association Congress, San Jose, CA, 1997.
The authors thank the participants at the AEM Consensus
Conference on Error in Emergency Medicine in San Francisco,
CA, May 2000. This paper represents a consensus of the views
expressed during both the workshop and summary sessions on
19. Wu AW, Folkman S, McPhee SJ, Lo B. How house officers
cope with their mistakes. West J Med. 1993; 159:565–9.
this topic. The authors express their thanks to Sherri Lamont 20. Leape L. Error in medicine. JAMA. 1994; 272:1851–7.
21. Wears RL, Leape LL. Human error in emergency medi-
cine. Ann Emerg Med. 1999; 34:370–2.
22. Wu AW. Medical error: the second victim. BMJ. 2000; 7237:
726–7.
for her excellent secretarial and computer skills, and to Calla
Farn for her significant input into the development of this pa-
per.
23. Croskerry P. The cognitive imperative: thinking about how
we think. Acad Emerg Med. 2000; 7:1223–31.
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