The emergency department (ED) is a high-risk environment for errors, and errors are inevitable for individuals working in such a complex and high-pressure environment. There are many interrelated factors that can lead to patient harm, and usually more than one factor is involved in each individual patient safety incident.

Through extensive research, both human and systemic factors have been identified as critical to patient safety. Understanding human factors helps to mitigate risks. Meanwhile, the environmental factor focuses on creating a workplace designed for the best possible outcomes for patients. Research conducted worldwide has shown that the main problems were the lack of guidelines and protocols, non-compliance with them, non-systematic recording and evaluation of errors, poor communication, ambiguity, confusion, and, of course, the need to rush due to the excessive number of patients. However, every weak point is actually an opportunity for intervention and improvement.

Within the framework of a just culture, a system is developed where there is open reporting but also appropriate accountability for each individual's actions. Developing and maintaining a culture of safety is a commitment to minimizing adverse events during high-risk tasks that could cause harm. Applying all the recommendations of researchers and institutional actors, we developed our framework. Through the systematic recording and monitoring of the data required in standardized forms, it became possible to directly evaluate the results of clearly defined procedures. This capability led to the continuous adjustment and redesign of procedures, with the constant criterion being the more effective operation of the ED and the higher quality of the health services provided.