Profiles in patient safety: emergency care transitions

Acad Emerg Med. 2003 Apr;10(4):364-7. doi: 10.1111/j.1553-2712.2003.tb01350.x.


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.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Diagnostic Errors*
  • Emergency Service, Hospital / standards*
  • Humans
  • Male
  • Medical Staff, Hospital
  • Middle Aged
  • Myocardial Infarction / diagnosis*
  • Panic Disorder / diagnosis
  • Panic Disorder / therapy
  • Patient Care Management / methods*
  • Patient Transfer*
  • Quality of Health Care*
  • Referral and Consultation
  • Safety