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An 83-year-old man with a history of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease, and paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for initiation of an antiarrhythmic medication and placement of a permanent pacemaker.

The patient underwent pacemaker placement via the left subclavian vein at 2:30 pm. A routine postoperative single-view radiograph was taken and showed no pneumothorax. The patient was sent to the recovery unit for overnight monitoring. At 5:00 pm, the patient stated he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that the patient's room air oxygen saturation had dropped from 95% to 88% and placed him on supplemental oxygen. She then paged the covering physician to come and assess the patient. The patient had been admitted to the nurse practitioner (NP)-run cardiology service earlier in the day (a non-house staff service), but at night, the on-call intern provided nighttime coverage for this service.

The intern, who had never met the patient before, examined him and found that he was already feeling better and that his oxygenation had improved after receiving the supplemental oxygen. The nurse suggested ordering a stat x-ray in light of the recent surgery. The intern concurred and the portable x-ray was completed within 30 minutes. About an hour later, the nurse wondered about the x-ray result and asked the covering intern if he had looked at it. The intern stated that he was signing out follow-up of the x-ray results to the night float resident, who was coming on duty at 8:00 pm.

Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave him analgesics and continued to monitor his heart rate and respirations. At 10:00 pm, the nurse still hadn’t heard anything about the x-ray, so she called the night float resident. The night float had been busy with an emergency but promised to look at the x-ray and advise the nurse if there was any problem. Finally at midnight, the evening nurse signed out to the night shift nurse, mentioning the patient's symptoms and noting that the night float intern had not yet called about the x-ray results.

The next morning, the radiologist read the x-ray performed at 6:00 pm the previous evening and notified the NP that it showed a large left pneumothorax. A chest tube was placed at 2:30 pm—nearly a full day after the x-ray was performed. Luckily, the patient suffered no long-lasting harm from the delay, but could have deteriorated rapidly. 1


In a perfect world, patients would stay in one place and be cared for by a single set of doctors and nurses. But, come to think of it, who would want such a world? Patients get sick, and then get better. ...

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