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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.
A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.