Did Emergency Department Provider Fatigue Contribute to This Patient’s Death?

Lisa McCorkle, MSN, MBA, Senior Patient Safety Risk Manager, Department of Patient Safety and Risk Management

The Doctors Company captures data on human factors that contribute to patient injury in malpractice claims. Of the 24,500 claims that closed between 2010 and 2020, 11.58 percent (n=2,837) included at least one human factor that influenced the care outcome.

Of the human factor claims, 5.5 percent (n=156) included conditions affecting the provider (such as distractions, multitasking, interruptions, fatigue, or physical or mental impairment). The following case example illustrates how human factors can affect patient care.

On December 25 at 2:04 AM, a patient presented to the emergency department (ED) with a chief complaint of chest achiness, sore throat, and congestion. The patient stated that “something just hit me all of a sudden.”

The patient denied having fever, chills, cough, nausea, or vomiting. The triage nurse noted the patient smelled of alcohol. The patient’s temperature was 101.4, pulse 131, respirations 22, blood pressure 135/78, and oxygen saturation 95 percent. The record noted the patient was a smoker, used alcohol and street drugs, and was on a six-month regimen of medications for exposure to tuberculosis. The triage nurse assessed that the patient was in no distress. The ED was understaffed and extremely busy that night. The patient was to remain in the waiting room until the next examination room became available.

At 5:20 AM, the patient was resting on chairs in the waiting room. When roused by the triage nurse, the patient still complained of feeling sick. The triage nurse checked again at 6:15 AM and noted that the patient was still resting on the waiting room chairs. Respirations were deep and even.

At 7:50 AM, the patient was escorted to the examination room. The patient, who now complained of cough, sneezing, body aches, and nasal congestion, was noted to be afebrile (although no vital signs were recorded). On exam by the nurse, the patient’s respirations were easy but with decreased breath sounds on the right to auscultation.

The patient was seen by a physician assistant (PA), who was working additional hours due to understaffing and had complained of fatigue earlier in the shift. The PA noted the patient’s vital signs from arrival at 2:04 AM (no other vital signs were ordered or documented during this ED visit) and the patient’s nonproductive cough, runny nose, and congestion. The PA documented an otherwise normal physical exam and negative medical history. The PA’s clinical impression was influenza and upper respiratory infection. The entire exam lasted less than 10 minutes. The patient was discharged home with instructions to rest, increase fluids, stop smoking, and follow up with a primary care physician in three to five days as needed. The ED physician—who did not see or examine the patient—countersigned the note.

The patient collapsed at home less than 48 hours later. Emergency medical services found the patient in asystole and apneic. They responded with defibrillation and cardiopulmonary resuscitation. The patient was transported to the ED and pronounced dead on arrival. An autopsy determined the cause of death to be bacterial pneumonia.

The claimant alleged that failure to diagnose and treat bacterial pneumonia led directly to the patient’s death.

Plaintiff’s Case

The plaintiff’s experts testified that with a temperature of 101.4, pulse rate of 131, and oxygen saturation of 95 percent, a chest x-ray and complete blood count (CBC) were indicated and should have been obtained. The experts opined that a chest x-ray would have shown the early stages of pneumonia and the correct diagnosis would have been made. The CBC would have shown an elevated white blood cell count, indicating a more severe infection.

The experts pointed out that taking only one set of vital signs on this patient was below the standard of care, since the first set was so clearly outside the normal range. The experts also noted that, given the patient’s abnormal vital signs and other symptoms, the hospital should have had policies requiring a physician to examine the patient before discharge.

The experts noted that the physical exam and medical history done by the PA were inadequate and did not meet the standard of care. The physician was faulted for not noticing the abnormal vital signs and minimal history on the PA’s note and for signing off on this patient without an examination before discharge.

Defense’s Case

Several defense experts were nonsupportive of the PA, ED physician, and hospital, citing the same concerns noted by the plaintiff’s experts. They also pointed out that the patient’s exposure to tuberculosis with medication treatment should have been investigated and that the long wait in the ED and the extremely brief examination by the PA were problematic and hard to defend.

The defense, however, found one supportive expert who said that the vital signs, while abnormal, could be consistent with influenza. The expert noted that the PA documented the physical exam as being within normal limits; if crackles or consolidation (indicative of possible pneumonia) had been present on auscultation, the PA would have documented it. The patient also had a nonproductive cough, as indicated by the PA. The expert opined that a chest x-ray and CBC were unnecessary and that a diagnosis of influenza was reasonable. The expert stated that the patient likely presented with influenza and subsequently developed an acute onset of bacterial pneumonia.


The patient’s presentation during the night shift of a major holiday, severe ED understaffing, and the PA’s admitted fatigue and hurry to finish the shift all contributed to the patient’s rushed and cursory examination.

Multiple factors in this case were difficult to defend: failure to order a chest x-ray and a CBC, failure to obtain additional vital signs or consider the patient’s complete medical history (including recent treatment for exposure to tuberculosis), and the long wait for an examination lasting less than 10 minutes.

Risk Mitigation Strategies

The following strategies can help you mitigate patient safety risks:

  • Promote a patient safety culture in which the recognition and prevention of practitioner and staff fatigue are addressed in the interest of patient safety.
  • Develop a teamwork environment in which team members practice situation monitoring of their ability to function effectively and monitor other team members for signs of fatigue or stress.
  • Cultivate a teamwork environment of mutual support in which team members feel free to express concerns to each other if they identify signs of fatigue or stress in their colleagues.
  • Monitor staff schedules, and curtail hours as needed to prevent undue fatigue.
  • Call in additional practitioners and staff to combat the problems of fatigue and stress.
  • Ensure adequate staffing levels on holidays and night shifts—in the ED and throughout the facility.
  • Manage large numbers of patients in the ED by maintaining contingency plans that include the following elements: maximum wait times; regularly monitoring patients in the waiting area, including recording vital signs; and guidelines for staff on calling for assistance.
  • Create policies and procedures to ensure that patients are seen in the ED promptly.
  • Recheck all patient vital signs before discharge, and notify the physician of any abnormal vital signs. Document the actions taken.

Provider fatigue and the rush to get things done when staffing levels are inadequate can lead to mistakes and poor patient outcomes. For additional strategies to address staffing shortages, read our article “Healthcare Staffing Shortages: Decrease Practice Risks.”

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.


Fatigue, sleep deprivation, and patient safety. PSNet. September 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety

The Joint Commission. Sentinel Event Alert 48: health worker fatigue and patient safety. December 14, 2011, with Addendum May 2018. www.jointcommission.org/sea_issue_48

Cheney C. Workforce shortages identified as top patient safety concern of 2022. Healthleaders. March 14, 2022. https://www.healthleadersmedia.com/clinical-care/workforce-shortages-identified-top-patient-safety-concern-2022

Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Impact of the COVID-19 pandemic on the hospital and outpatient clinician workforce: challenges and policy responses. Issue Brief No. HP-2022-13. May 2022. https://aspe.hhs.gov/sites/default/files/documents/9cc72124abd9ea25d58a22c7692dccb6/aspe-covid-workforce-report.pdf

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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