On May 22, workers and patients at the Texas Diabetes Institute on Zarzamora were disrupted by the sound of a fire alarm, followed by a code red.
"It was pretty crowded that day and then, when the fire alarm went off, it was chaos," said a clinic visitor.
A woman on the second floor of the clinic, who prefers to remain anonymous, remember feeling helpless.
"One of the other ladies told a man, an amputee, 'Can you walk? Go downstairs without your cane?' He said yes (and) started hopping, jumping with his cane," a visitor said.
One man, who was assisting a friend that day, remembers feeling like everything was in slow motion.
"There was no way I was going to be able to take my friend down the stairs because it's pretty steep," he said.
University Health System Senior Vice President of Facilities Mark Webb said it was a false alarm.
There was no smoke and no fire, but there was a seven-minute gap between the time the alarm went off and the time the all clear was given.
It was during this time that the staff was investigating the cause of the alarm.
But it was also during this time that some of the patients were getting mixed messages.
"The staff that were able to grab some of the patients, they got out. A lot of the patients stayed behind. The staff didn't come back for the rest," said the visitor.
Webb said if there is smoke or fire, the order to evacuate is clear, but if there is no smoke and no fire, the mandate is a little less clear.
Either way, Webb insists employees need to do a better job communicating.
"Let them know that in case of evacuation that they will lead them to a safe path to get out of the building," Webb said.
Going forward, Webb would like to see staff provide confidence and leadership in reassuring patients.
Webb added one of the changes that will come from this incident is adding text messaging as a mode of communicating the all clear.