Beyond the Dual Control Tower: Directions for Reforming the National Emergency Medical System to Enhance Patient Safety and Ensure Continuity in South Korea

Recurrent difficulty securing emergency department (ED) acceptance and delayed interfacility transfer, often resulting in multiple sequential transfer attempts ("round-robin" hospital seeking), in the Republic of Korea reflect a patient safety failure across the emergency care continuum, spanning Emergency Medical Services from emergency calls and prehospital care to ED stabilization, definitive treatment, and secondary transfer.We argue that the governance split between the National Fire Agency-led prehospital response and the Ministry of Health and Welfare-led emergency medical system fragments accountability and data, undermining sustainable quality management.We describe a "double bind" in which clinicians face medico-legal risk regardless of acceptance decisions, distorting transfer behavior.We propose an outcome-linked Quality Improvement system-integrated metrics, interoperable data linkage, operational medical control, and routine feedback-to strengthen Continuity of Patient Care.This requires functional integration of the dual command structure; transferring ambulance service functions to the Ministry of Health and Welfare, or an equivalently strong joint-governance model, should be evaluated.Regionally, responsibility-based systems should be implemented through councils that set transfer principles and resource allocation, supported by stable financing and performance review, with the regional emergency medical situation room providing medical control and real-time coordination.For mass-casualty incidents, preparedness should align standardized triage, integrated command and communication, training, and after-action review.Legal reform is a necessary starting point, but trust and sustained patient safety depend more on cultivating a learning-oriented safety culture grounded in patient experience and public deliberation throughout policy design and implementation.