By Kate Sullivan

In discussing the case of Lewis Blackman today, I could not help but think about the importance of good transfer of care. If the on-call weekend resident had a better understanding of Lewis’ immediate post-op progress (or lack of), the gradual change in his vital signs and exam may have sent up red flags sooner. It is easy to become overwhelmed with the number of unfamiliar patients one must cover as an on-call physician. One may not appreciate the subtle changes in a patient’s status when there is just a snap-shot view of the situation. We have all fallen victim to this, and the situation is worsened by sleep deprivation. I can recall a case when a patient had subtle labs changes over the course of her stay for preeclampsia. To the covering physician, these labs seemed relatively stable and the patient was sent home. She returned the next day actively seizing from eclampsia. Because of this, I am now in the habit of reviewing the record of all the patients I am covering before, or at the start, of my shift.  This is an additional layer of protection beyond our otherwise thorough patient hand-offs. It is important to appreciate the “big picture” in addition to the details.


One Response to By Kate Sullivan

  1. Patrick Smith says:

    Day two of this conference was another amazing experience. I continue to be constantly surprised and impressed by all of the participants at this conference. It is very humbling to be in the presence of people of such outstanding quality with firm convictions to make the health care they give the best and safest it can be. I commend everyone on their character, heart and innovation. These people are inspiring in every sense of the word.

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