PC 12: Emergency Department Quality Assurance Workshop

This pre-course will be virtual-only

Course Director

  • Barbara Masser, MD


  • Barbara Masser, MD. USA
  • Jonathan Edlow, MD. USA
  • Jon Burstein, MD. USA
  • Roberta Petrino, MD. Italy
  • Ian Higginson, MD. UK


The course is designed for 30 participants. 

Target group: emergency physicians and nurses interested in emergency department quality improvement 

Course description 

The goal of this course is to provide a hands-on practicum in quality review for emergency medicine incorporating both US and European perspectives.

Learning objectives

After this one day course, participants will learn:

  1. The necessity of having a well-run quality program in their EDs and the importance of using quality metrics to measure ED performance, drive intended clinical behaviors, and ensure high-quality care delivery to patients in emergency medicine clinical practice through the creation of a blame-free culture.
  2. The structured review technique, applying it to three specific clinical cases with the goal of determining the presence or absence of error and its most likely source (provider, systems, supplies, protocol deficiency, administrative).
  3. The creation of a clinical pathway (through hands-on practice), and important concepts regarding the use of clinical pathways to improve patient safety.
  4. How to define an error (versus “judgment”), differentiate errors in planning (mistakes) from errors in execution (slips and lapses), distinguish between errors and adverse events, rate an error using the AHRQ Adverse Event Severity Scale, discuss factors contributing to errors, and understand the relationship between error and standard of care


This course addresses Section 2.6 - 4 Health care evaluation and improvement from the European EM curriculum


Wednesday 27 October

11.00-11.30 Why Quality Assurance is Essential to Every Emergency Department

This introductory session will be a discussion of the necessity of having a well-run quality program and the importance of using quality metrics to measure ED performance, ensure high-quality care delivery, and create a blame-free culture.

11:30-13:30 Workshop 1: Performing Case Review and Objectifying Error: How to perform a structured case review & objectifying error. 

After a brief instruction, learners will break into a group discussion, facilitated by all course faculty, and jointly “review” three specific clinical cases applying the technique of the introduced structured review. At the end of this exercise, participants will have determined the presence or absence of error and its most likely source (provider, systems, supplies, protocol deficiency, administrative).

13:30-14:00  Break

14:00-16:00 Workshop 2: Reducing Error through Pathways

First, we will discuss the development of multi-disciplinary clinical pathways to reduce error in the emergency department (introduction to the clinical problem, what was the scenario that led the department to feel the need to create a clinical pathway?). After the introduction, we will take the “error” identified in our earlier workshop for each specific case and discuss ways in which this could be prevented in the future. The group will engage in strategic brainstorming and discussion of potential clinical pathway development around these specific clinical issues, as well as multi-disciplinary considerations (dealing with consulting services, interaction with hospital administration).  

16:00-16:15  Break

16:15-17:15 Conclusion & QA Challenge Panel

During this session, participants will bring their biggest QA challenges to the table. The four international faculty members will propose potential solutions, discussing their experiences with QA management at their home departments. At the end of the session, we will summarize the techniques reviewed (structured case assessment, objectifying error, clinical protocol and pathway development).