Profiles in patient safety: Emergency care transitions

Christopher B Beach*, Pat Croskerry, Marc Shapiro

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

87 Scopus citations

Abstract

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.

Original languageEnglish (US)
Pages (from-to)364-367
Number of pages4
JournalAcademic Emergency Medicine
Volume10
Issue number4
DOIs
StatePublished - Apr 1 2003

Keywords

  • Leadership
  • Medical error
  • Patient safety
  • Psych-out error
  • Transitions

ASJC Scopus subject areas

  • Emergency Medicine

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