A 46-Year-Old Man Has Been Admitted to the Hospital with Diabetic

A 46-year-old man has been admitted to the hospital with diabetic ketoacidosis. He is given intravenous fluids and an insulin drip, and lab tests are scheduled. The on-call physician transfers the patient to the day shift physician in the morning, who comes an hour late owing to an emergency at his overnight moonlighting job. The patient's state and instructions to monitor electrolytes and compute his anion gap are included in the handoff information. The doctor does inpatient rounds and then his typical clinic outpatients in the afternoon, but he forgets to check the patient's anion gap. The patient's acidity worsens, necessitating intubation for respiratory distress. Which of the following is the most likely reason for this unfortunate outcome?

A) Deficiency of knowledge
B) Excessive patient caseload
C) Inadequate patient handoff
D) Judgment error
E) Physician burnout
F) Physician fatigue

Correct Answer:

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