Patient safety in emergency departments: a problem for health care systems? An international survey : European Journal of Emergency Medicine

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Original Article

Patient safety in emergency departments: a problem for health care systems? An international survey

Petrino, Robertaa; Tuunainen, Eevab; Bruzzone, Giuliaa; Garcia-Castrillo, Luisc

Author Information
European Journal of Emergency Medicine ():10.1097/MEJ.0000000000001044, May 24, 2023. | DOI: 10.1097/MEJ.0000000000001044



According to the WHO definition: ‘Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce impact of harm when it does occur’ [1]. The safety culture [2] is influenced by human factors, where every professional should be incentivized by managerial support and by organisational factors to prevent errors and to increase safety, including all the processes and structures that may help to prevent errors [3,4].

Emergency medicine is considered a high-risk specialty [5] as there is a rapid turnover of patients, direct contact with the outside, overcrowding, and the frequent need to divert and respond to life-threatening situations, all of which produce fertile ground for the occurrence of adverse events and increase the challenges in maintaining patient safety compared to more regulated and ordered health care environments [74.7, 95% confidence interval (CI) 72.28–77.11] [6–8].

As described in 2020 by a consensus of experts at the International Federation of Emergency Medicine Symposium, safety is one of the six main elements that constitute quality in the delivery of emergency care (the others being effectiveness, equity, readiness, efficiency, and a patient-centred system) [9]. While the parameters to measure safety are quite specific [10], risk factors for errors in the emergency department (ED) can be set at patient level (acuity, complexity, or cognitive barriers), at provider level (cognitive errors, training impairment, burnout, sleep cycle disruption, communication and handover, number of decisions), or at environmental level (overcrowding, interruptions, time) [7–9].

Besides medical errors, protection from violence, infection risk, and respect for the dignity of the person are other important safety issues in the ED [10].

Emergency medicine also frequently suffers from difficult working conditions and a shortage of adequately trained professionals due to high turnover. This means that staff are often junior and inexperienced. It is well known that suitable supervision by experienced emergency physicians can greatly reduce the risk of errors [11–13].

Despite all the risk factors, the ED is thought to be a safer place than other hospital work environments, like surgery [13,14]. Nevertheless, the frequent difficulties related to workload and overcrowding not only add to the overall risk to the patient but may increase burnout and a feeling of lack of safety in staff [15–17]. This was clearly described in the 2022 Emergency Medicine Day campaign [16], when 39 national and international emergency medicine societies signed a position statement on factors they felt were necessary in order to be able to work safely in the ED (74.7, 95% CI 72.28–77.11) [18].

The current Emergency Medicine Day campaign explores professionals’ perception of safety through a validated questionnaire [19,20]. The aim is to see whether the existing safety culture and the implementation of safety procedures are sufficient to provide safety or if it is necessary to tackle the structural and systemic problems that undermine patient and professional safety in the ED.

Study design

This was an observational study based on a cross-sectional online survey. Using Survey Monkey as the platform, study participants were recruited from professionals working in health care (HCPs) who were active in emergency medical systems. The survey was disseminated through the European Society of Emergency Medicine (EUSEM) network, with 20 000 primary contacts in the distribution list along with a secondary distribution through National Societies and other institutions. The survey reached an estimated 40 000 target professionals and was carried out over 4 weeks (30 January–27 February 2022). During the survey period, one reminder was sent.

A pilot study was used to test the questionnaire and was sent to 40 HCPs; 27 responses were received and analysed. No further explanatory requests were required by the respondents. No validation was felt necessary for the questionnaire as the survey was based on an ED safety questionnaire previously developed in the United States by Magid et al. [19], which had previously been modified and validated by the Royal College of Emergency Medicine [20], using the validity index [21] for each question. This questionnaire is oriented towards the safety of both patients and professionals and is organized in five different domains: teamwork, safety leadership, physical environment and equipment, staff and external team, and organisational factors and informatics, with different items for each domain.

Additional questions were included, explored in previous studies in different health settings oriented to the infection control and team morale domains [22]. Each domain was composed of different independent questions, designed as 36 ordinal scale questions. There were three questions on age, gender and years of professional experience, and a postal code as the centre identifier. In response to each question, the respondent could select from five different levels of agreement or a ‘do not know’ option. The questionnaire is presented in Supplementary Appendix I, Supplemental digital content,

A score was drawn up for each domain by simple addition of the questions’ values according to the five possible responses, using the following ranking: never (1), rarely (2), sometimes (3), usually (4), and always (5). Inverse ranking was used in the negative questions. The higher the score, the safer the situation. A cut-off point using the 75th percentile level of the score distribution was used to create a dichotomic variable of the score; this cut-off point was selected by author consensus. Respondents with more than 10 years of activity were classified as experienced professionals.

Sample size calculation was estimated on the assumption that the target population could reach 40 000 professionals. The estimation of the necessary number of responses with a 95% CI and a 3% margin of error, using 50% as the assumed answer proportion of the population, was 1040 respondents [23,24].

For the analysis, Cronbach’s alpha [25] was calculated across the seven domains to estimate the internal consistency. Safety assessments were made using descriptive statistics after aggregating the five response levels into three categories (never/rarely, sometimes, usually/always), including the 95% CI distribution, using the Wald method [26]. X2 was used in the inferential analysis, exploring the effect of gender, profession, and experience as possible confounding factors. The significant statistical level was set at a P value of <0.05. SPSS 17 (IBM, Armonk, New York, USA) platform was used for the analysis.

The study did not require a Research and Ethics Committee review but received approval from the EUSEM board of directors.


The survey included 1256 responses from 101 different countries; 70% of these responses came from Europe. Twenty-one countries provided more than 20 questionnaires, corresponding to 76.5% of the total sample. The estimated response rate was 3.14%. The respondents included 645 females (51.1%), 607 males (48.2%), and four identifying as other genders. Most of the respondents were doctors (1045, 84%) and nurses (199, 16%), with a small group of 12 (<0.1%) allied professionals including paramedics, pharmacologists, and public health workers. The respondents were experienced professionals in 688 cases (54.8%). The level of agreement between the questionnaire statements using Cronbach’s alpha and the response distribution aggregated by the five different domains are shown in Tables 1 and 2.

Table 1 - Response distribution for teamwork, safety leadership, physical environment, and equipment
Safety in the emergency department
Domains Response distribution
N (%) [95% CI]
N (%) [95% CI]
N (%) [95% CI]
Cronbach’s alpha.621
Interruptions disrupt the ability of staff to provide care * 87 (7.04) [5.61–8.46] 476 (38.51) [35.8–41.22] 673 (54.45) [51.67–57.23]
Doctors and nurses work well together in the ED 22 (1.75) [1.03–2.48] 197 (15.7) [13.68–17.71] 1036 (82.55) [80.45–84.65]
Important clinical information is lost in handovers at the change of shift * 435 (34.91) [32.26–37.56] 665 (53.37) [50.6–56.14] 147 (11.8) [10.01–13.59]
There is good communication of patient management between doctors and nurses 48 (3.83) [2.77–4.89] 331 (26.42) [23.98–28.86] 874 (69.75) [67.21–72.3]
Safety Leadership
Cronbach’s alpha.758
There is an open, non-judgemental environment for reporting safety concerns 213 (17.36) [15.24–19.48] 322 (26.24) [23.78–28.7] 692 (56.4) [53.62–59.17]
New nurses are well mentored by nurses with more experience 170 (14.19) [12.21–16.17] 355 (29.63) [27.05–2.22] 673 (56.18) [53.37–58.99]
ED leadership takes action to improve safety of clinical care for patients 165 (13.36) [11.46–15.26] 321 (25.99) [23.55–8.44] 749 (60.65) [57.92–63.37]
Protocols are used for high risk or complex medication administration (e.g. sedation, thrombolytic, blood, etc.) 113 (9.08) [7.48–10.67] 202 (16.22) [14.18–18.27] 930 (74.7) [72.28–77.11]
Junior or unexperienced doctors are adequately supervised in the ED 184 (14.83) [12.85–16.8] 315 (25.38) [22.96–27.8] 742 (59.79) [57.06–62.52]
Physical Environment and Equipment
Cronbach’s alpha.752
It is easy to find the professionals caring for a specific patient 148 (11.86) [10.07–13.65] 393 (31.49) [28.91–34.07] 707 (56.65) [53.9–59.4]
Mental health patients are cared for in a safe environment 420 (34.79) [32.13–37.44] 365 (29.53) [26.99–2.07] 441 (35.68) [33.01–8.35]
Monitoring devices function in the ED 58 (4.65) [3.48–5.82] 184 (14.74) [12.78–16.71] 1006 (80.61) [78.42–82.8]
There is sufficient space for delivering care 465 (37.53) [34.83–40.23] 338 (27.28) [24.8–29.76] 436 (35.19) [32.53–37.85]
ED personnel feel physically safe while working 232 (18.5) [16.35–20.65] 293 (23.37) [21.02–25.71] 729 (58.13) [55.4–60.86]
Staff and External Team
Cronbach’s alpha.730
Medical staffing is sufficient to handle patient load during busy periods 583 (46.6) [43.84–49.37] 388 (31.02) [28.45–33.58] 830 (22.38) [20.07–24.69]
Initial assessment/triage works well in my department 102 (8.13) [6.62–9.65] 302 (25.68) [23.26–28.1] 830 (66.19) [63.57–68.81]
Monitoring of vital signs/Early Warning Scores are used effectively 147 (11.74) [9.96–13.52] 278 (22.2) [19.9–24.51] 827 (66.05) [63.43–68.68]
Nurse staffing is sufficient to handle patient load during busy periods 646 (51.72) [48.95–4.49] 345 (27.62) [25.14–30.1] 258 (20.66) [18.41–22.9]
The number of patients cared for exceeds the capacity of the ED to provide safe care * 100 (8.06) [6.55–9.58] 397 (32.02) [29.42–34.61] 743 (59.92) [57.19–62.65]
CT scans are completed within 1 h when clinically indicated 287 (23.03) [20.7–25.37] 380 (30.5) [27.94–3.05] 579 (46.47) [43.7–49.24]
Organisational Factors and Informatics
Cronbach’s alpha.765
Hospital procedures are effective at improving flow in the ED 590 (47.62) [44.84-50.4] 408 (32.93) [30.31-35.55] 241 (19.45) [17.25-21.66]
ED staff feel pressurized by external targets over patient care * 154 (12.59) [10.73-14.45] 406 (33.2) [30.56-35.84] 663 (54.21) [51.42-57]
Effective systems are in place to highlight patient alerts (e.g. allergies. risk of falling) to ED staff 219 (17.58) [15.46–19.69] 366 (29.37) [26.84–31.9] 661 (53.05) [50.28–55.82]
Hospital managers support improvements in patient safety in the ED 429 (35.43) [32.73–8.12] 417 (34.43) [31.76–37.11] 365 (30.14) [27.56–32.72]
It is difficult to gain access to patients’ hospital medical records when needed * 645 (51.81) [49.03–54.58] 380 (30.52) [27.96–33.08] 220 (17.67) [15.55–19.79]
It is difficult to gain access to patients’ primary care records when needed * 327 (26.59) [24.12–29.05] 368 (29.92) [27.36–32.48] 535 (43.5) [40.73–46.27]
Patients are transferred to a hospital bed in a timely manner (no crowding due to boarding) 701 (59.71) [56.98–62.44] 313 (25.22) [22.81–7.64] 233 (18.78) [16.6–20.95]
Procedures to report errors and near misses are user-friendly 444 (37.15) [34.42–39.89] 327 (27.36) [24.84–29.89] 424 (35.73) [33.02–38.45]
There is an adequate number of functioning computers in the ED 310 (24.8) [22.41–27.19] 242 (19.36) [17.17–21.55] 698 (55.84) [53.09–8.59]
Cronbach’s alpha: validity of the group of questions (values from 0 to 1).
%, percentage of valid responses in the group; 95% CI, 95% confident interval; N, number of responses.
*Inverse ranked.

Table 2 - Response distribution for infection control and team morale
Safety in the emergency department
Domains Response distribution
N (%) [95% CI]
N (%) [95% CI]
N (%) [95% CI]
Infection Control
Cronbach’s alpha .442
Leadership takes action to grant infection control in the ED 214 (17.57) [15.43–19.71] 297 (24.38) [21.97– 26.8] 707 (58.05) [55.27–60.82]
There are enough PPE supplies to protect professionals 104 (8.44) [6.89–9.99] 148 (12.01) [10.2–13.83] 980 (79.55) [77.29–81.8]
Team Morale
Cronbach’s alpha.782
I am less effective at work because of fatigue and burnout * 236 (18.8) [16.64–20.97] 550 (43.82) [41.08–46.57] 469 (37.37) [34.69–40.05]
I am proud to work in emergency medicine 69 (5.52) [4.25–6.78] 133 (10.63) [8.92–12.34] 1049 (83.85) [81.81–85.89]
Morale in my ED is high 306 (24.72) [22.31–27.12] 373 (30.13) [27.57–32.69] 558 (45.07) [42.3–47.84]
This is a good place to work 194 (15.51) [13.5–17.51] 394 (31.49) [28.92–31.07] 663 (53) [50.23–55.76]
Working in my ED is like being part of a large family 126 (10.09) [8.42–11.76] 302 (24.18) [21.8–26.55] 821 (65.73) [63.1–68.36]
Cronbach’s alpha: validity of the group of questions (values from 0 to 1).
%, percentage of valid responses in the group; 95% CI, 95% confident interval; N, number of responses.
* Inverse ranked.

The reported scores for each domain are presented in Table 3, including the 75th percentile of the score.

Table 3 - Domain score characteristics
Domain score characteristics
Domains No. of issues No. Of responses Range Mean (SD) Median 75th percentile
% N
Teamwork 4 1229 4–20 13.26 (1.69) 13 15 327
Safety leadership 5 1145 7–25 18.52 (3.61) 19 21 356
Physical environment and equipment 5 1204 7–25 16.9 (3.49) 17 20 313
Staff and external team 6 1221 6–28 17.97 (3.84) 18 21 351
Organisational factors and informatics 9 1109 9–45 26.10 (5.62) 26 30 315
Infection control 2 1195 2–10 7.68 (1.61) 8 9 411
Team morale 5 1219 5–25 17.48 (3.60) 18 20 385
N (%), number of responses over the 75th percentile cut-off point; No. of issues, number of assessments in the domain; SD, standard deviation..

The effects of profession, experience, and gender on the estimated relevance of each statement are highlighted in Table 4, highlighting possible confounding factors on the distribution of the calculated score split by the 75th percentile cut-off point.

Table 4 - Effect of profession, gender and experience on the estimated safety issues
Effect of respondents’ characteristics on the safety evaluation
Domain score Profession Gender Experience
75th percentile Doctor Nurse P Female Male P <10 years >10 years P
 Over 75th 87% 13% ns 48.0% 52.0% ns 45.3% 54.7% ns
 Serie 84.3% 15.7% 51.4% 48.6% 44.7% 55.3%
 Total responses 1218 1220 1229
Safety leadership
 Over 75th 90.6% 9.4% .000 44.5% 55.5% .014 35.7% 64.3% .001
 Serie 84.9% 15.1% 49.9% 50.1% 42.6% 57.4%
 Total responses 1134 1136 11,45
Physical environment and equipment
 Over 75th 89.1% 10.9% .008 42.9% 57.1% .001 41.5% 58.5% ns
 Serie 84.3% 15.7% 50.8% 49.2% 44.5% 55.5%
 Total responses 1194 1196 1204
Staff and external team
 Over 75th 87.1% 12.9% ns 43.6% 56.4% .001 42.7% 57.3% ns
 Serie 84.4% 15.6% 50.9% 49.1% 44.6% 55.4%
 Total responses 1211 1212 1221
Organisational factors and informatics
 Over 75th 85.2% 14.8% ns 44.9% 55.1 .049 41.0% 59.0% ns
 Serie 85.0% 15.0% 49.6% 50.4% 42.4% 57.6%
 Total responses 1100 1101 1109
Infection control
 Over 75th 87.5% 12.5% .044 46.7% 53.3% .047 38.9% 61.1% .005
 Serie 84.5% 15.5% 50.7% 49.3% 44.5% 55.5%
 Total responses 1184 1186 1195
Team morale
 Over 75th 87.7% 12.3 .021 47.1% 52.9% ns 41.3% 58.7% ns
 Serie 84.1% 15.9% 51.0% 49.0% 45.2% 54.8%
 Total responses 1209 1211 1219
P ns, > 0.05
Total responses, number of valid cases for the analysis in this domain.


The survey provided a representative sample of international ED settings. Based on the Cronbach’s alpha analysis, nearly all the questions in each explored domain showed consistency, with values similar to those obtained in previous publications in more uniform settings [10]. The exception was in the infection control domain, which had a low Cronbach’s alpha that therefore limits its interpretation. Teamwork had the lowest consistency, similar to a previous validation in the United Kingdom [20]. The demographic characteristics of the sample showed a realistic distribution of gender. There was a clear over-representation of doctors over nurses.

With respect to safety among emergency medicine professionals, the majority of respondents considered that they were working in a safe environment. It is important to recognize, as previously reported, that such a perception can lead to the under-reporting of risk events [27]. On the other hand, the survey showed that ED staff felt pressurized by external targets over patient care, and 54.2% reported that they were always under external pressure.

The perceived support from the hospital would appear inadequate; 35% reported that in their view hospital managers never supported the introduction of improvements, and 47% considered that hospital procedures were never effective in improving flow in the ED. This result would appear to highlight the difficulties of integrating ED objectives with general hospital objectives.

Human resources were identified as a significant safety concern, with 46.6% of doctors and 51.7% of nurses reporting that staffing was insufficient during busy periods. Among the respondents, 59.9% highlighted that at times the number of patients cared for exceeded the capacity of the ED to provide safe care. They reported that boarding (difficulty admitting patients to the hospital wards) was one of the basic causes of ED overcrowding and its known consequences [28]. Indeed, 59% of respondents highlighted that admissions to hospital beds never happened in a timely manner.

The care of mental health patients was considered to be a particular safety issue; 34.7% of respondents highlighted that in their ED a safe environment for such patients did not exist [29].

These results seem to provide clear evidence of a system under pressure that directly threatens safety and which is in direct contradiction to the commitment made in the WHO action plan [1]. While medical devices and IT technology were not considered a major problem, the amount of space in the ED was considered to be problematic; 37.5% reporting that care was being provided in insufficient space.

Other recognized aspects that may compromise patients’ and professionals’ safety, such as loss of information at handover, supervision of young professionals, adequate access to patient information, clinical procedures (triage, clinical assessment, protocols, alerts), and leadership in the ED were not considered relevant safety risk issues by respondents.

The working model in the ED has classically been described as multitasking, with frequent interruptions a major consequence [30]. This last aspect was recognized by the respondents as a factor affecting safety [31]. Our survey confirmed the relevance of such interruptions; 54.4% of respondents reported that interruptions always disrupted the ability of staff to provide care.

Comparing these results with the UK Secure study, the reported estimations are similar in all domains and with respect to specific questions, more precisely in the identification of aspects that may compromise the safety of patients such as interruptions, loss of information at handover, structural problems, insufficient human resources, compromised care of mental health patients, and the importance of the exit blocking [20].

To estimate the level of safety, a score per domain was created, obtained by aggregating the values of the individual questions. Although the five Magid domains and the domain for team morale had similar score distributions, safety leadership and team morale showed the highest number of responses over the cut-off point, while the physical environment and teamwork had the smallest number of respondents over the selected cut-off point, highlighting that more attention to the latter two domains is probably required.

Professional experience, gender, and health workers’ professional status affected the estimation of the safety domains. Compared to doctors, nurses tended to have a lower perception of safety in the safety/leadership, physical environment/equipment, and team morale domains. This consistent reduction in the evaluation of the different safety aspects is likely to be related to the fact that nurses work in closer proximity to patients for longer periods and is something that has been reported in previous publications [20].

Female respondents had a lower level of safety perception in all domains except teamwork and team morale. Females highlighted and were more critical regarding patient safety. Less experienced professionals had a lower estimation of safety levels in the safety leadership domain. One of the components of this domain is the supervision of young professionals, which may explain their more critical judgement of this crucial aspect.

An encouraging result of our study was the analysis of the team morale domain, which found that 83.8% of professionals reported that they were always proud to work in the ED, and 53% reported that they would always recommend the ED as a workplace. This further supports the recognition of emergency medicine as a medical speciality and to the need to protect this workforce.

The survey shows that safety remains an issue for emergency medicine, with many EDs suffering major structural and organisational problems. Several possible solutions are suggested, including defining a satisfactory ratio of professionals to patients; monitoring and responding to the peak patient flow as a reference point; evaluating daily bed needs and capacity so as to regulate elective and ED admissions without delay; and implementing fast tracks and nursing procedures to improve access and flow through ED ambulatory care.

To date, 35 national and international scientific societies have signed a position statement requesting the minimum acceptable standards necessary to work safely in the ED. The results of this current survey demonstrate that we are far from being at that preferred point. Our hope is that hospital managers and policymakers will take the problem into serious consideration and provide solutions.


This study presents some limitations on survey quality that are inherent in the survey methodology. The distribution of the survey to an unknown target population size creates uncertainty about the response rate, the best estimation being less than 5% of those that received the survey. This low response rate may compromise the quality of the results based on non-response bias, and possible information bias due to the selection of more professionals who are critical of their workplace.

The low number of responses from a majority of the countries limits the possibility of country-specific analysis and may reduce the applicability to those countries. The over-representation of specific centres (multiple responses from the same centre) and the exclusion of some information about centre types (academic centres versus rural hospitals, for example) may be a source of information bias that needs future analysis.

The smaller number of nurses (16%) included in the survey responses may limit the validity of the respondents’ opinion as these professionals are underrepresented in this sample.

However, the broad distribution of the survey across different countries with different health systems is one of the strengths of the study which overcomes the negative effect on the precision of the results due to variability.


In this international survey of healthcare professionals working in EDs, the majority of respondents identified the ED as an environment with an insufficient level of safety, as defined by the WHO. The main reasons appear to be a shortage of personnel in busy periods, overcrowding due to boarding, and insufficient perceived support from hospital management.


The authors acknowledge Mrs Willemijn van Hess for her constant and careful support in setting up and distributing the survey, collecting data, and coordinating the Emergency Medicine Day group, and Mary Rice for editing the paper.

Conflict of interest

There are no conflicts of interest


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boarding; emergency department; emergency medicine; overcrowding; patient safety; survey

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