Profiles in Patient Safety: Emergency Care Transitions
Article first published online: 8 JAN 2008
Academic Emergency Medicine
Volume 10, Issue 4, pages 364–367, April 2003
How to Cite
Beach, C., Croskerry, P. and Shapiro, M. (2003), Profiles in Patient Safety: Emergency Care Transitions. Academic Emergency Medicine, 10: 364–367. doi: 10.1111/j.1553-2712.2003.tb01350.x
- Issue published online: 8 JAN 2008
- Article first published online: 8 JAN 2008
- received December 4, 2002 accepted December 5, 2002.
- patient safety;
- medical error;
- psych-out error
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.