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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.
Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].
This story describes how hospitals in the United Kingdom have incorporated teamwork principles used by auto racing pit crews to improve patient safety during handoffs.