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The White Elephant in the Room

Airline crews maintain schedules that are highly regulated and monitored, and for good reason. Studies have shown there is increased risk of pilot and flight crew error when they work excessive hours, especially during the transition to a new aircraft when additional focus is needed to adapt to a new environment and equipment.

Healthcare is no different, yet providers are generally expected to self-regulate and monitor their own time and circumstances. The following case addresses the dangers of going too fast and spreading yourself too thin. Long work hours, extended back-to-back workdays, changing work environments, and overloaded patient schedules can all cause physicians to overlook obvious issues and lead to more errors in clinical disagnoses and judgment.  

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A 45-year-old female, “Ms. Patient,” with a history of diabetic neuropathy, hypertension, hyperglycemia, and high BMI was seen in a medical office for complaints of left shoulder pain that occurred after heavy lifting. On presentation to the clinic, Ms. Patient’s heart rate was 128/minute. Ms. X, a physician assistant (PA), examined Ms. Patient. She assessed Ms. Patient as having muscle spasms and back pain and treated her with a Decadron injection and a prescription for Cyclobenzaprine.  

Two days later, Ms. Patient called the medical office complaining of vomiting and a transient fever following the Decadron injection. The front office staff advised her to go to the emergency room (ER), which Ms. Patient declined. The PA, Ms. X, subsequently spoke with Ms. Patient. Ms. Patient reported no abdominal pain or diarrhea, so Ms. X prescribed Zofran. Later that evening, Ms. Patient presented to an urgent care clinic complaining of vomiting, dizziness, and the "room spinning" for the prior two days. She was seen by Dr. Y. Ms. Patient’s heart rate was again 128 and glucose was 284. Dr. Y diagnosed Ms. Patient with vertigo and sent her home with a prescription for Phenergan.

The following day, Ms. Patient presented to the ER complaining of shortness of breath, right-sided weakness with facial droop, and slurred speech. An EKG showed ischemia and acute myocardial infarction (MI). Ms. Patient was admitted to the hospital. Her admitting diagnosis was diabetic ketoacidosis (DKA), myocardial infarction, and cerebrovascular accident (CVA) from a left cerebral arterial occlusion. 

In the claim that followed, Ms. Patient alleged her diabetes and cardiac condition went unaddressed, leading to DKA, MI, and right-sided CVA.  Ms. Patient was critical of the care that she received by the PA at the medical office and the physician at the urgent care clinic. The case subsequently resolved informally prior to trial.

Although there were several clinical issues identified in the care and treatment of Ms. Patient in the medical office setting, our attention primarily focuses on the nonclinical, or systems issues, at the urgent care center when Dr. Y saw Ms. Patient. On review, it was noted the urgent care clinic was a high volume, very busy center and its processes may not have provided adequate time to address patient conditions. Dr. Y, who saw the patient, was working multiple days and long hours, including back-to-back 12-hour shifts at several urgent care centers and medical office practices.

Fatigue can be a significant contributing factor to inattention to detail, e.g., overlooking tachycardia and abnormal lab results, not obtaining a thorough medical history, or not ordering further testing.

The electronic medical record (EMR) at the urgent care center did not have a functioning alert system that notified providers of abnormal vital signs or lab results, unlike another location where the physician practiced. When working at multiple locations with different EMRs and alert systems, it can be difficult to remember what each system does or does not do, especially if a physician is fatigued, distracted, or rushed. Technology can be great, but it should serve to supplement, not replace, one’s critical thinking skills.

Had the patient been referred to the ER by Dr. Y on the last encounter at the urgent care center, both the MI and the CVA may have been averted.  And yes, had the patient gone to the ER when told to by the front office staff at the medical office clinic, maybe the MI and the CVA could have been avoided. Perhaps if the PA or
the doctor spoke with the patient instead of the receptionist, the patient would have been more receptive to the advice.

The moral of the story is that the providers didn’t see the elephant in the room (diabetes and tachycardia). Risk factors that can contribute to oversight include:

  • Overloaded work schedule/inadequate rest
  • Inadequate provider to patient time intervals/excessive patient-to-provider volume
  • No documentation on patient education on the increased risk of DKA with steroid use
  • No labs on a diabetic presenting with nausea/vomiting
  • No functioning EMR alert system

There remains controversy on study methodologies and results on medical error statistics.  One study ranks error as the third leading cause of death in the U.S,i and another ranks it much less.ii Mathematically, the lower of these estimates equates to a 747 airplane crash every 90 minutes. Aren’t we glad pilots and airline crews don’t fly back-to-back 12-hour shifts? 

Lee McMullin is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to