WebM&M Cases & Commentaries
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- Discontinuities, Gaps, and Hand-Off Problems
- Interruptions and distractions
- Latent Errors
- Spotlight Case
Christopher Fee, MD; February-March 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.