The Holiday Rush of Risk: What Off-Hour Data Reveal About Patient Safety

As much of the world winds down for the holidays, essential workers don’t experience the same luxury. The season of celebration often means long shifts, reduced staffing, and a steady stream of patients who can’t wait for normal business hours. As a result, when the pace of life slows down elsewhere, the risks inside hospitals and clinics can quietly rise.

The Weekend and Holiday Effect

Candello’s national medical malpractice database reveals that among 31,156 cases closed between 2020 and 2024, 2,762 (9% of all cases) occurred during a weekend or holiday period. Even though these cases aren’t as frequent, they can be more costly and severe than cases that don’t occur on weekends and holidays.

These numbers confirm what many clinicians already feel: care delivered outside of standard weekday hours carries added risk. Weekends and holidays test every layer of the system from handoffs and staffing ratios to diagnostic vigilance and patient monitoring.

Diagnosis Tops the List

Across all specialties, diagnosis-related issues were the leading major allegation, accounting for 26% of cases. These included delayed or missed diagnoses, often compounded by limited access to testing or specialists during off-hours. Close behind were medical (non-OB) treatment and surgical treatment allegations (each at 19%), followed by safety and security (17%) and obstetrics-related treatment (8%).

The data suggest that both cognitive and systemic factors are at play. Reduced staffing and resource availability can lengthen response times, but human factors—fatigue, communication breakdowns, and overreliance on incomplete information—often turn risk into harm.

Settings and Services Under Pressure

The majority of weekend and holiday cases occurred in inpatient settings (57%), with another 19% in emergency departments and 13% in ambulatory environments.

Notably, each service area had its own pattern of vulnerability:

• For Nursing services, safety and security issues, particularly patient falls, were most common.
• Improper management of a surgical patient was the most frequently cited in Surgery cases, while the delay in treatment of fetal distress was the top major allegation when Obstetrics/Gynecology was named as the primary responsible service in a case.
• For nearly all other services, diagnosis-related allegations remained the primary reason behind claims.

The Human and System Factors Behind the Numbers

Candello’s analysis of co-occurring contributing factors paints a familiar picture of interconnected risks:

• Patient assessment issues appeared in 65% of cases, highlighting the ongoing challenge of accurate and timely evaluation.
• Selection and management of therapy (43%) and provider-to-provider communication failures (34%) followed close behind.
• Patient monitoring issues (27%) and provider-patient communication breakdowns (22%) rounded out the top five.

These patterns reveal that most harm doesn’t result from a single lapse—it’s the accumulation of small misses. A delayed lab result. A missed handoff note. A patient who didn’t fully understand discharge instructions on a busy weekend evening.

Added Risk at Night

The data also point to a critical subset: cases occurring during night shifts, regardless of the time of the week or year. These carried the highest severity and greatest financial impact, with 45% involving death and average total losses of $525,000. The combination of a weekend or holiday and a night shift only further intensifies the risk of breakdowns in care.

Building Resilience into Off-Hour Care

While the risks are clear, they also highlight opportunities for targeted improvement. Hospitals and health systems can:

• Strengthen handoff protocols between day and night teams, for example, implementing handoff tools such as I-PASS.
• Use real-time communication tools that bridge provider and specialty gaps.
• Ensure staffing flexibility to match patient acuity during holidays and weekends.
• Reinforce fall prevention and monitoring protocols when nurse-to-patient ratios are stretched.
• Provide ongoing education and simulation training focused on diagnostic reasoning under pressure.

Technology can assist, but as Candello’s broader research shows, it cannot replace the clarity and consistency of human communication. The goal isn’t to eliminate weekends or holidays from the risk equation; it’s to design systems resilient enough to withstand them.