When urgency is invisible: an ER physician's misplaced assumption
A real-world example of Illusion of transparency in action
Context
A busy urban emergency department was operating at 120% capacity during an overnight influenza surge. A senior emergency physician (EP) had a strong, immediate concern about a middle-aged patient with sepsis but was juggling admissions, phone consults, and documentation.
Situation
The EP believed her alarmed facial expression and terse comments during handoff would communicate the level of urgency to the admitting internal medicine team. She briefly said, "This one worries me," and assumed the on-call hospitalist would prioritize transfer to ICU and begin broad-spectrum antibiotics promptly. No explicit request, checklist, or readback was used during the handoff because the EP felt her concern was obvious.
The bias in action
The EP experienced the illusion of transparency: she overestimated how much her internal sense of urgency and nonverbal cues would be perceived by others. The admitting team interpreted the handoff as routine because the wording was vague and competing tasks occupied their attention. Because the EP did not state a clear action request (e.g., "Please accept to ICU now and start piperacillin-tazobactam within 30 minutes"), the hospitalist placed the patient on the general unit and ordered antibiotics on the regular med-surg schedule. Team members later reported they did not realize the EP thought immediate ICU-level care was required.
Outcome
The patient experienced a 45-minute delay in administration of the first dose of broad-spectrum antibiotics and was transferred to the ICU only after vitals deteriorated. The delay was noted in the department morbidity review; the patient ultimately recovered but required an additional 48 hours in ICU and an extra two-day hospital stay compared with similar presentations. The incident prompted a formal communication debrief and a near-miss report.