Profiles in Patient Safety: Emergency Care Transitions


  • Christopher Beach MD,

    Corresponding author
    1. Division of Emergency Medicine, Northwestern University – The Feinberg School of Medicine, Chicago, IL (CB).
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  • Pat Croskerry MD, PhD,

    1. Department of Emergency Medicine, Dartmouth General Hospital Site, Halifax, Nova Scotia, Canada (PC)
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  • Marc Shapiro MD

    1. Department of Emergency Medicine, University of Florida HSC/Jacksonville, FL; the Department of Emergency Medicine, Rhode Island Hospital, Brown University, Providence, RI (MS)
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Division of Emergency Medicine, 676 North St. Clair Street, Suite 2125, Chicago, IL 60611. Fax: 312-926-6274; e-mail:


A 59-year-old man presented to the emergency department (ED) with the chief complaint of “panic attacks.” In total, he was evaluated by 14 faculty physicians, 2 fellows, and 16 residents from emergency medicine, cardiology, neurology, psychiatry, and internal medicine. These multiple transitions were responsible, in part, for the perpetuation of a failure to accurately diagnose the patient's underlying medical illness. The case illustrates the discontinuity of care that occurs at transitions, which may threaten the safety and quality of patient care. Considerable effort must be directed at making transitions effective and safe. Recommendations to improve transitions include a heightened awareness of cognitive biases operating at these vulnerable times, improving team situational awareness and communication, and exploring systems to facilitate effective transfer of relevant data.