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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 his oxygenation had dropped from 95% to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient. The patient was on the nurse practitioner (NP)-run non-house staff service; however, the on-call intern provides coverage for patients after the NPs leave for the day.

The intern, who had never met the patient before, examined him and found him already feeling better and with improved oxygenation after receiving the supplemental oxygen. The nurse suggested a stat x-ray be done 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 and asked the covering intern if he had seen it. The intern stated that he was signing out the x-ray 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 called with any bad news.

The next morning, the radiologist read the x-ray performed at 6:00 pm 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.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. Doctors and nurses work shifts, and then go home. Residents graduate from their programs and enter practice. So handoffs—the process of transferring primary authority and responsibility for clinical care from one departing ...

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