Most of us rely on emergency rooms when we, or a loved one, have an urgent healthcare need. Whether it’s due to a high fever, chest pains, or a car accident, we go to the ER for high-quality care, often with time-sensitive needs. However, there are emergency room safety concerns that can hamper our ability to receive timely, quality care.
Note that the terms “emergency room” and “emergency department” are often used interchangeably. In actuality, emergency department is a better descriptor of not only the size of most emergency facilities, but also of the large scope of services and care provided. However, for ease of reading, I use the term “emergency room” throughout this post.
This post covers the following emergency room safety concerns:
- Diagnostic errors.
- Staffing issues.
- Medication errors.
Emergency room safety concerns: Overcrowding due to “boarding”.
When it comes to emergency room safety concerns, overcrowding is one we should all have concerns about. If you’ve been to an ER lately, you’ve likely experienced crowding, which is not only annoying, but it’s also dangerous. Unsurprisingly, ER crowding is correlated with discomfort, reduced privacy, treatment delays, and higher risk of prolonged disease and death. Additionally, there is widespread evidence that crowded ERs lead to medical error, staff burnout, and excessive cost.
Yes, staffing issues and increased demand for ER services lead to overcrowding and the associated long waits, but that is a small part of the problem. A bigger problem? Patient boarding.
Boarding is one of the most serious emergency room safety concerns.
Importantly, experts believe overcrowding in ERs is primarily due to boarding – the practice of keeping admitted patients in the ER until hospital beds become available. Unsurprisingly, doctors admit many ER patients to the hospital for further testing, treatment, and attentive care. But without available beds, admitted patients can board in the ER for hours, days, or even weeks. Shockingly, mental health patients can wait months for a bed.
Boarding is bad for patients and for ER staff. In fact, in a survey of over 2,500 ER doctors, respondents reported that inpatient boarding was their largest safety concern (followed by availability of specialty consultation and nursing shortages).
To reduce harm, The Joint Commission (an agency dedicated to improving healthcare quality) recommends a 4 hour maximum for ER boarding. But there is no formal rule or requirement.
Importantly, experts consider ER boarding as a critical indicator of the quality of care provided by a hospital. Yet, the American College of Emergency Physicians reports that boarding has reached a crisis level. The bottlenecks overwhelm hospitals, cause dangerous delays, and put patients’ lives at risk. Simply put, due to boarding, emergency care teams are “strained to their limits“.
Boarding can lead to patient harm, including longer wait times, increased medical errors, and compromises to patient privacy. Additionally, ER boarding can lead to worse outcomes for patients, longer inpatient stays, and higher costs of care. In some cases, boarding can even lead to death.
And boarding patients often lie on gurneys in the hallways – with no privacy, and constant exposure to bright lights and noise. Patients stuck in hallways for prolonged periods include patients who need sensitive exams, highly infectious patients, and elderly patients.
ERs are not designed for long-term care.
Unsurprisingly, ER staff are not trained to take care of patients for an extended period, a task made harder by the diversion of their attention to emergency situations. Instead, ER staff excel at identifying and treating life-threatening illnesses and injuries, resuscitative care, and diagnostics. And, the burden of boarding patients can lead to poor job satisfaction and decreased staff engagement.
Boarding strains ER nurses.
ER nurses often bear the brunt of boarding admitted patients. Not only do nurses have to care for new patients, but they also must care for boarding patients, some of whom are quite ill and waiting for an ICU bed. To put this in perspective, a nurse on a medical floor may care for 4 or 5 patients. In the ICU, a nurse may care for 2 patients. Yet, in an ER, a nurse may care for 10 or more patients!
Boarding can reduce access to care.
Once admitted, boarded ER patients usually receive care from ER nurses, who are overwhelmed and overworked. However, hospitalists (inpatient doctors) generally take over for the ER doctors, requiring them to visit the ER to access and treat patients. This is hard for doctors since traveling down to the ER takes time out of an already overwhelmingly busy workload. Interestingly, some hospitals cope by assigning a hospitalist to work in the ER to take care of boarding patients.
Additionally, ERs may not have monitoring equipment boarding patients need, including for high-risk patients heading to ICUs. Certainly, this lack of proper monitoring can increase the risk of patient harm.
Boarding causes long waits and dangers for patients in waiting rooms.
When boarding patients take up valuable ER beds, the waiting time for new ER patients increases. For instance, a November, 2022 Boston Globe article reports waits as long as 8 hours.
Unsurprisingly, patients’ conditions can worsen during a long wait. In fact, some patients die in the waiting room before they even get a chance to see a doctor!
And longer waits lead patients to leave before being seen. Of course, leaving without an evaluation or treatment can lead to delayed care, which can result in significant harm.
Boarding stories from ER doctors.
The American College of Emergency Physicians collected more than 100 personal stories from emergency doctors that illustrate the dangers of the situation.
ER doctors share stories of patients with brain bleeds, hip fractures, and necrotizing genital infections receiving treatments in the waiting room because the ER had no rooms or even hallway beds available.
One doctor reports that out of their 22 ER beds, there were 35 patients boarding and 20 patients in the waiting room. Additionally, the average time for boarding was 70 hours per patient, although one patient boarded for over 200 hours.
Why do hospitals allow widespread ER boarding?
Experts agree – it’s all about money. High-margin elective surgery patients are a substantial driver of hospital revenue. But when they keep their medical floors filled with elective surgery patients, there are not enough beds available for ER patients.
How can this problem be solved? Research shows that when hospital occupancy exceeds 85%, boarding in the ER occurs. Therefore, experts believe the best way to solve ER boarding is to change the payment system so hospitals can be economically viable with inpatient capacities of 90% or less, which would leave enough beds available for admitted ER patients.
Can you learn how often your local hospital uses patient boarding in the ER?
As mentioned above, there are no laws or rules regarding a maximum boarding time. Additionally, hospitals are not required to report their boarding statistics.
Interestingly, in 2016, Centers for Medicare & Medicaid Services (CMS) gave hospitals the option of report on boarding times. Unsurprisingly, the hospitals who voluntarily reported boarding times were not reaching crises levels, leading CMS to discontinue this metric in 2021. Of course, it seems obvious that a hospital with long boarding times would simply not voluntarily report the data. It certainly doesn’t mean boarding isn’t an issue.
Unfortunately, the lack of reporting requirements makes it close to impossible for people to learn about boarding practices at hospitals in their area.
Emergency room safety concerns: Diagnostic errors.
A diagnostic error is any mistake or failure in the diagnostic process that causes a doctor to make a wrong diagnosis, a missed diagnosis, or a delayed diagnosis. Of course, this can lead to patient harm as patients may receive no treatments, the wrong treatment, or experience a delay in treatment.
Unfortunately, diagnostic errors occur in all locations where patients receive care, including in the ER.
Researchers from John Hopkins conducted a study for the Agency for Healthcare Research and Quality, Their systematic analysis of past research studies and malpractice claims found that ER diagnostic error rates are comparable to those found in primary care and hospital inpatient care. However, the potential for harm is large due to the sheer volume of ER visits, with 130 million ER visits every year in the US.
For instance, the researchers found an estimated diagnostic error rate of 5.7%, which translates to more than 7 million errors every year. Furthermore, they found that approximately 2% of patients experience misdiagnosis-related harm, leading to harm in over 2.5 million patients each year. Alarmingly, the team estimates that every year, ER diagnostic errors lead to 100,000 patients experiencing permanent, high-severity disabilities and 250,000 deaths.
Importantly, these diagnostic error rates translate to about 1 in 18 ER patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death.
Who is more likely to experience a diagnostic error in an ER?
Unsurprisingly, the researchers found a variation in diagnostic error rates across demographic groups. Firstly, they found that age can impact error rates for particular conditions. For instance, doctors are more likely to miss a stroke in younger patients and more likely to miss appendicitis in older patients.
Additionally, females and those of non-white race had an increased risk of misdiagnosis, although the disparities varied across studies.
As you’d expect, some hospitals had higher rates of diagnostic errors than others. However, error rates were generally lower in academic/teaching hospitals, although the researchers don’t know why this is the case.
What types of conditions caused the most frequent harms?
Over two-thirds of serious harms from diagnostic errors are attributable to just 15 diseases (below, listed in order of frequency), with the top 5 on the list accounting for 39% of serious misdiagnosis-related harms.
- Myocardial infarction (heart attack)
- Aortic aneurysm and dissection
- Spinal cord compression and injury
- Venous thromboembolism (blood clot in a vein)
- Meningitis and encephalitis
- Lung cancer
- Traumatic brain injury and traumatic intracranial hemorrhage
- Arterial thromboembolism (blood clot in an artery)
- Spinal and intracranial abscess
- Cardiac arrhythmia
- Gastrointestinal perforation and rupture
- Intestinal obstruction
What caused these diagnostic errors?
The analysis found that errors were often caused by more than one factor. However, they found that 89% of diagnostic error malpractice claims involved failures in decision-making or judgment, regardless of the type of underlying disease. Interestingly, they found the key failures were errors in diagnostic assessment, test ordering, and test interpretation. Moreover, these errors were often due to inadequate knowledge, skills, or reasoning, particularly when patients had subtle or atypical symptoms.
This study evaluated performance in ERs over a period of 20 years. However, much of the data came from ERs in Canada and Europe.
Dr. David E. Newman-Toker, a lead author of the study states they only included data from countries with ER operations similar to the US, leading them to include data from ERs in the US, Canada, UK, Western Europe, Australia, and New Zealand.
Importantly, most of the studies reviewed took place before the COVID pandemic. Dr. Newman-Toker believes COVID adversely impacted diagnostic accuracy in the ER. When an ER is overwhelmed and overcrowded, he expects that it’s easier for doctors to misdiagnose patients, especially those with subtle symptoms.
Fortunately, there are steps you can take to reduce your risk of diagnostic errors. For tips, read 10 Steps to Reduce Your Risk of Diagnostic Error.
Emergency room safety concerns: Staffing issues.
It’s stressful to work in an emergency room. ER doctors and nurses face increasing pressures to meet productivity metrics, such as how long patients wait to be seen and the total time patients spend in the ER. Additionally, staff must reduce the risk of patients returning to the ER by properly diagnosing and treating patients, while leaving patients satisfied with the care received.
Expectedly, to run smoothly, ERs need the right number of staff with the right balance of skills. Unfortunately, this can be difficult for hospitals. This post covers four issues in ERs relating to staffing that can impact patient care and safety:
- Inadequate staffing levels.
- Insufficiently trained staff.
- Irregular working hours.
- Increasing reliance on medical staffing companies.
Inadequate staffing levels.
Unfortunately, the healthcare industry is currently facing unprecedented staff shortages, including in the ER. In fact, since February 2020, 18% of healthcare workers have quit their jobs, and 12% have lost their job. Healthcare workers report they left their jobs due to COVID, insufficient pay or opportunities, and burnout.
ECRI, an organization focused on healthcare technology and safety, reports that inadequate staffing actively jeopardizes patient safety. Staffing shortages lead to long waits for care, even in life-threatening emergencies. And in some cases, shortages force hospitals to turn patients away.
Inadequately trained staff.
Approximately 40% of emergency medicine doctors do not have board certification. Although those without certification may perform well, they may be inadequately trained. Unsurprisingly, emergency medicine doctors with less experience make more errors than experienced doctors, creating a serious safety risk for ER patients. Furthermore, doctors without emergency medicine residency training must learn on the job, sometimes without a more experienced doctor mentoring them.
Difficult working hours.
As you know, the ER runs 24/7, requiring doctors, nurses, and other staff to work night shifts. Research shows that rotating shift work disrupts sleep, causes fatigue, and creates problems with thinking, memory, and decision making. Unsurprisingly, a lack of sleep is associated with increased medical errors.
Medical staffing companies.
Staffing in ERs is changing as hospitals look to cut costs and increase profits. Increasingly, hospitals outsource their ER staffing to medical staffing companies, mostly owned by private equity investors.
Two firms dominate the ER staffing industry, both owned by private equity companies: TeamHealth and Envision Healthcare. Additionally, American Physician Partners is a rapidly expanding company that runs ERs in at least 17 states and is 50% owned by a private equity firm.
It’s all about the money.
One of the ways these staffing companies save hospitals money is by using fewer doctors and more midlevel practitioners, such as nurse practitioners (NPs) and physician assistants (PAs).
These midlevel practitioners can perform many of the same duties as doctors, generating much of the same revenue while being paid less than 50% of doctors’ pay. Although this saves money on salaries, it may not be an improvement for patients.
How many hospitals use ER staffing companies?
Dr. Arthur Smolensky, a Tennessee emergency medicine specialist, set out to answer that question. He reviewed hospital job postings and employment contracts in 14 major metropolitan areas. He found that 43% of ER patients were seen in ERs staffed by companies with non-doctor owners, nearly all of whom are private equity investors.
Concerns about private equity in healthcare.
You may have noticed an increase in private equity companies investing in healthcare. Many critics, including myself, have serious concerns that these firms focus more on money and less on patients. Personally, the practices for my dermatologist and optometrist have been purchased by private equity firms and I sensed a change right away.
Do we want companies run by non-doctors telling our doctors how to treat us? I know I don’t!
Yet, many ER doctors who have worked for private equity staffing companies say the firms’ mission doesn’t align with the best practice of medicine. For instance, doctors note that staffing companies emphasize speed and patient volume over safety. Additionally, these doctors share that companies prefer lesser-trained, lower cost providers. And alarmingly, the doctors state the companies dictate treatment protocols that may be unsuitable for certain patients.
Does reducing the number of doctors impact the quality and cost of care?
Generally, nurse practitioners and physician assistants have master’s degrees and specialized training. Many states allow NPs and PAs to diagnose patients and prescribe medication with little or no supervision from a doctor, but rules vary by state. Importantly, they have significantly less training than doctors.
Unfortunately, when midlevel practitioners treat patients without input from doctors (who receive more training), patients are more vulnerable to misdiagnoses and inadequate care.
For instance, a working paper published in October 2022, analyzed over 1 million visits to 44 ERs throughout the Veterans Health Administration, where nurse practitioners can treat patients without oversight from doctors. The study found that ER patients treated by nurse practitioners were 20% more likely to be readmitted to the hospital for a preventable reason within 30 days, although the overall risk of readmission was very small.
Additionally, the researchers found that when nurse practitioners treated patients, the costs increased by an average of 7%, while the length of stay in the ER increased by 11%.
Unsurprisingly, one of the study’s authors notes that some of these differences could be mitigated by using nurse practitioners with more experience. Additionally, the author suggests that nurse practitioners should take care of patients with simpler health concerns, unless no doctor is available.
Smaller studies also find differences.
A small study found non-doctor practitioners in ERs were associated with a 5.3% increase in imaging, which could lead to higher medical bills for patients.
Similarly, a primary care study (not an ER) found that midlevel practitioners increased the out-of-pocket costs for patients. Additionally, in this primary care study, midlevel practitioners had worse performance on nine of 10 quality-of-care metrics, including rates for cancer screenings and vaccinations.
However, the jury is still out on the safety and quality of care provided by midlevel practitioners in ERs.
ER doctors take a stand against private equity staffing firms.
Dr. Smolensky shares that many doctors feel the increasing use of private equity staffing companies has changed the ER landscape. ER doctors feel demoralized by an increased focus on profit, causing many experienced doctors to stop practicing emergency medicine.
Importantly, a group of emergency doctors and consumer advocates are pushing the government to enforce old laws that prohibit companies not owned by licensed doctors from owning medical practices. Regulators created these laws and rules to maintain the independence and authority of doctors, and to prioritize the doctor-patient relationship over the interests of investors and shareholders.
Thirty-three states, plus the District of Columbia, have laws banning the corporate practice of medicine. But companies skirt the law by buying or creating local staffing groups that have a doctor with a nominal ownership stake. And then they restrict the doctor’s authority, giving him/her no direct control of the business.
ER doctors are also reaching out to Attorneys General and state Medical Boards but have faced obstacles and frustration.
Currently, doctors and advocates are waiting to see the results of a California lawsuit against Envision. Success in the case, scheduled to start in January 2024 in federal court, could lead to widespread changes. But a positive outcome is far from certain.
Does your local ER use a staffing company?
Unfortunately, it’s hard to learn if your ER uses a staffing company – it’s not something a hospital advertises or shares widely.
Emergency room safety concerns: Medication errors.
Medication errors are the most frequently reported error in emergency rooms, with medication error rates estimated between 4-14%. Alarmingly, the medication errors rates for pediatric patients in ERs can be as high as 39%. It doesn’t help that more than 75% of ER visits include medication, representing over 210 million medication encounters every year in the US.
Medication errors can cause patient harm, or even death, although in the US, over 95% of medication errors cause no patient harm.
What kinds of medication errors can occur?
Medication errors can involve a range of mistakes, including:
- Prescribing or administering the wrong medication.
- Wrong dosage.
- Overlooking a known medication allergy.
- Wrong time.
- Missed dose.
- Wrong method of medication delivery.
However, research shows that dosing errors are the most common, causing between 40-50% of medication errors.
What leads to medication errors in ERs?
There are many reasons why ERs have higher rates of medication errors including:
- Overcrowded ERs.
- Inadequate staffing levels.
- The urgent needs of patients.
- There is often little time to access medical records.
- ER staff generally do not know ER patients and their medical histories.
- Patients may arrive alone, with no one available to share important medical history.
- ER staff may have to prescribe and administer medications when pharmacists are unavailable for safety checks.
- Reliance on verbal orders, which staff can misunderstand or misinterpret.
- Failure to have verbal orders confirmed by repeating the instructions.
- Lack of independent double-checks for medications prepared by nurses, such as IV infusions.
One study gathered anonymous information on medication errors from staff at almost 500 ERs in the US. The results include:
- Both doctors (24%) and nurses (54%) reported responsibility for medication errors.
- The most common time for errors was during the administration of medications.
- Improper dose or quantity were the most common errors.
- The leading causes of errors were:
- Not following procedure or protocol.
- Poor communication.
- Emergency situations.
- Increase in workload levels.
What can you do?
If you are alert, or you have someone with you, these tips can reduce your risk of a medication error:
- Make sure the doctor and nurse have an accurate list of your current medications, including over-the-counter drugs. Don’t rely on your medical records. Your doctors may not have access to a complete record. Plus, most medical records contain errors of some sort. Therefore, always carry a medication list with you and share as needed.
- When a doctor prescribes medications, jot down (on your phone or a piece of paper) the medication name, dosage, and instructions (e.g., orally, at meals, etc.). Ask what the medication is for, and about possible side effects.
- Before taking a medication, ask the nurse to confirm the medication and dosage. Check this against the notes you took when the doctor prescribed the medication.
- Speak up if you have concerns.
For more tips, read Medication Errors in Hospitals – How Can You Protect Yourself?
Final thoughts regarding emergency room safety concerns…
Now that you read about emergency room safety concerns, you may have concerns about going to an emergency room. Although I am not a doctor, and my suggestions are not “medical advice”, I recommend you go to an ER if you think you have a serious, potentially life-threatening condition. However, if you don’t think your condition is life-threatening, you may want to call your doctor or try an urgent care center before going to an ER.
For more information on this topic, read Do You Need an ER, Urgent Care or Retail Clinic?