Knowledge Center | ProAssurance

Recognizing and Referring Emergent Cases in Urgent Care Centers: Strategies for Patient Safety and Quality Care

Written by Anne Marie Lyddy | July 2025

Urgent Care Centers (UCCs) play a critical role in providing timely and convenient healthcare services for patients with episodic, subacute illnesses and injuries. However, it is essential for healthcare providers in UCCs to be able to recognize and appropriately refer cases that require care beyond the center’s capabilities. This article aims to discuss the importance of recognizing emergent cases and implementing risk reduction strategies in UCCs to help ensure patient safety and quality care.

Case Study

A patient presented to a UCC following a high-speed motor vehicle accident with complaints of nausea, joint pain, myalgia, and neck pain. The patient exhibited bony tenderness and an obvious deformity of the left shoulder, indicating a potential acromioclavicular joint separation. Unfortunately, the healthcare provider failed to perform an abdominal exam or order a CT scan of the abdomen and pelvis, despite the patient’s left rib tenderness.

Approximately seven hours later the patient collapsed at home and was found pulseless by emergency medical technicians. Despite resuscitation efforts the patient ultimately succumbed to his injuries. Postmortem examinations revealed significant injuries to the spleen, liver, and head. The patient’s family sued the UCC physician alleging his failure to identify the patient’s traumatic injuries and refer him to a higher level of care resulted in his death.

Expert Opinions and Causation

Several expert opinions were sought in the case study. While there were varying opinions on the exact cause of death, all experts agreed that the patient’s splenic injuries played a significant role. The failure to diagnose and treat the splenic injury earlier resulted in hemorrhagic shock and subsequent cardiac arrest. Additionally, the delayed recognition of a head injury led to a prolonged period of anoxia and a severe anoxic/hypoxic brain injury.

Importance of Recognizing Emergent Cases

The case study highlights the importance of recognizing emergent cases in UCCs and promptly referring them to higher-level facilities. While UCCs are not intended to treat medical emergencies, they should be adequately prepared to handle emergencies or conditions that require care beyond their capabilities. This requires a comprehensive evaluation of the UCC’s scope of practice, physical plant, staffing, equipment, information management, and clinical protocols.

Risk Reduction Strategies

To help ensure patient safety and quality care, UCCs should implement the following risk reduction strategies:

  • Scope of Services: Clearly define the UCC’s scope of services, ensuring it aligns with the center’s capabilities and target patient population.
  • Diagnostic and Treatment Protocols: Use a systems-based approach to develop and implement diagnostic and treatment protocols within the scope of services offered. Establish clinical guidelines for the services provided.
  • Emergent Clinical Scenarios: Identify clinical scenarios that require referral to a higher level of care, categorizing them as emergent. Consider the mechanism of injury, regardless of clinical presentation, in certain instances.
  • Stabilization and Transfer: Develop policies and procedures for stabilizing patients and facilitating their transfer to higher-level facilities when their needs exceed the UCC’s capabilities.
  • Emergency Referral Criteria: Establish criteria for contacting 911 or arranging transport to an emergency facility for patients with life-threatening conditions.
  • Transfer Agreements: Develop transfer agreements with local and regional higher-level facilities to ensure a smooth transition for patients requiring advanced care.
  • Network of Medical Specialists: Connect with a network of medical specialists to facilitate timely referrals and consultations when necessary.
Diagnostic Errors and Strategies for Improvement

Diagnostic errors can have serious consequences for patients and can also lead to medical liability claims. To help prevent diagnostic errors and reduce the risk of medical liability claims, healthcare professionals should implement various strategies.

  • Diagnostic process improvement: Enhance cognitive skills and work within health systems to improve the diagnostic process. The Society to Improve Diagnosis in Medicine (SIDM) offers resources to help healthcare professionals enhance their cognitive skills and make more precise and timely diagnoses.1
  • Cognitive and Affective Influences: Explore the Clinical Reasoning Toolkit offered by SIDM to gain insight into the causes of errors in clinical reasoning and the key factors in making more mindful decisions.2
  • Tools and Guidelines: Use checklists, algorithms, mnemonics, and clinical practice guidelines to provide a systematic approach to diagnosis and avoid cognitive biases and errors.
  • Patient Outcomes Follow-up: Gain feedback on diagnostic performance and identify areas for improvement. Use these lessons as opportunities for staff education and training to continuously advance learning and improve diagnostic accuracy.
  • Thorough Documentation: Ensure that documentation includes all relevant information about the patient’s history, physical exam, diagnosis, treatment plan, and any follow-up care needed. Incorporate patient education efforts and obtain patient acknowledgment of the care plan to mitigate the risk of noncompliance and improve patient outcomes.
Conclusion

Recognizing emergent cases and appropriately referring them to higher-level facilities is crucial for patient safety and quality care in Urgent Care Centers. By implementing risk reduction strategies such as improving decision-making, utilizing tools and guidelines, following up on patient outcomes, and ensuring thorough documentation, healthcare professionals can reduce liability risk and provide exceptional care to their patients.

References
  1. Improving Diagnosis in Medicine Change Package,” Society to Improve Diagnosis in Medicine, accessed August 15, 2023. https://www.improvediagnosis.org/improving-diagnosis-in-medicine-change-package/
  2. Clinical Reasoning Toolkit: How We Make Decisions,” Society to Improve Diagnosis in Medicine. accessed August 15, 2023, https://www.improvediagnosis.org/clinical-reasoning-toolkit-how-we-make-decisions/