title: Profiles in patient safety: emergency care transitions.
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.
authors.affiliation: Department of Emergency Medicine, University of Florida HSC/Jacksonville, FL, USA. cbeach@nmff.org
authors.forename: Christopher
authors.initials: C
authors.lastname: Beach
authors.forename: Pat
authors.initials: P
authors.lastname: Croskerry
authors.forename: Marc
authors.initials: M
authors.lastname: Shapiro
mesh_terms: D003951:Diagnostic Errors; D004636:Emergency Service, Hospital / Q000592:standards*; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis*; D016584:Panic Disorder / Q000175:diagnosis / Q000628:therapy; D010346:Patient Care Management / Q000379:methods*; D010360:Patient Transfer; D011787:Quality of Health Care; D012017:Referral and Consultation; D012449:Safety