Setting: Nursing station with lots of noise, sound of monitors. Time 4:15 p.m.
Dr. Thomas: Josh, you're on tonight, right?
Dr. Best: Yeah, at 5, and I've still got 2 discharges to do.
Dr. Thomas: Ok well, I'm trying to make it out in time for journal club so I'm going to sign out. 6B who came in this afternoon with abdominal pain. He had some blood work and X-rays but he's booked for an abdominal CT tonight.
Nurse: (interrupting) Dr Thomas, can Mr. Mcknight have something more for his pain? (Dr. Thomas sighs and writes order hurriedly.) His BP is 95/60.
Dr. Thomas: (His pager goes off.) I'm never going to get out of here. Have a good one! (Taps Dr. Best with clipboard and leaves in haste.)
Setting: Resident responds to page in hallway. Time 10:30 p.m.
Voice in background: Dr. Best, call 14928 please. Dr. Best...
Dr. Best: It's Dr Best. You paged?
Nurse: (excitedly on the phone) Dr. Best, Mr. Mcknight is crashing! The ICU team was called.
Dr. Best: Who?
Nurse: Mr. Mcknight in 6B who came in with the abdominal pain. Dr Thomas told you all about him. ICU wants to know his code status.
Dr. Best: (looking puzzled) I have no idea.
Nurse: Well, with his history of cancer ...
Dr. Best: (alarmed) What cancer?
Nurse: And they mentioned something about the free air on his X-rays.
Dr. Best: I thought Dr. Thomas looked at his x-rays!
Nurse: He couldn't have. They weren't even done until after he left.
Dr. Best: I don't believe this! I'll be right there.
Concluding facilitation question: What factors contributed to this poorly performed handover?