Abstract
Through an urgent patient case of acute limb ischemia and intervention, care transitions are examined. The importance of safe, consistent transitions of care has become even more apparent after the COVID-19 pandemic when face-to-face communication was inhibited in many areas. The impact of urgent patient needs coupled with a high number of inexperienced staff enhances the need for appraisal of current handoff communication practices in all patient care areas. The reality is this; many of the most serious medical errors are linked to miscommunication. This ischemic limb patient case highlights inconsistencies in patient care transition processes and the associated risks that need to be addressed to improve patient care.
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