Exploring contributing factors to fatalities occurring within an emergency department: a qualitative analysis informed by root cause analysis principles

Abstract

Emergency Departments (EDs) are highrisk and timepressured workplaces where latent system failures can quickly culminate in fatal outcomes. Understanding the underlying causes contributing to mortality in these units is therefore essential for designing effective safety interventions. This qualitative study, informed by Root Cause Analysis (RCA) principles, aimed to identify factors contributing to ED fatalities in a referral hospital in Urmia, Iran. All ED deaths recorded during 2021–2022 ( n = 595) were reviewed. Because medical records contained limited information on contributory factors, the study integrated non-participant observations, semi-structured interviews with five purposively selected key informants, and a targeted literature review. Qualitative content analysis was used to identify themes, which were subsequently organized into a fishbone diagram using RCA principles. The most common immediate causes of death were cardiac arrest, loss of consciousness, shortness of breath, and road traffic injuries. Seven interacting categories of contributing factors emerged: patient-related issues, communication and teamwork failures, individual staff performance lapses, physical and social environment constraints, managerial and organizational deficiencies, equipment/medication/supply failures, and external factors. Frontline staff perceived that multiple systemic vulnerabilities, particularly communication gaps, resource shortages, and organizational constraints, interact to increase the risk of fatal outcomes in this ED. However, this exploratory study cannot establish direct causality or determine the proportion of preventable deaths. The findings highlight the need for an integrated Electronic Health Record (EHR) system, standardized team training for shift handovers, adequate staffing aligned with national standards, and patient safety education to foster a proactive safety culture. The effectiveness of these proposed interventions should be evaluated in future formal, case-level RCA studies.