Hospital communication systems failure leads to patient death

Written By Thomas Hall

When a medical catastrophe happens, it is often not simply the result of one person making a careless mistake; more typically, the failure of the hospital to have safety systems in place to act as a safety net results in unnecessary death or disability. These errors, commonly referred to as “systems failures”, have plagued the medical profession for decades. Unlike other industries, such as the airline industry, when a catastrophe occurs, hospitals often fail to conduct an adequate root cause analysis. Without learning how a mistake happened, the steps taken to remedy the situation, if any, are typically inadequate.

Such is the case of a 40-year-old woman, mother of four children, who came to the emergency room because she had been ill for weeks and running a fever for over a week. She had a catheter in her chest in order to receive medications to assist with her severe asthma. But a catheter can also act as a portal for infection. The emergency room physician recognized the risk that this patient could have a serious blood-borne infection and ordered blood cultures. Blood cultures take at least a day, if not longer, to yield positive or negative results. Rather than keep the patient in the hospital and start her on presumptive antibiotics, the emergency room doctor sent her home. The emergency room doctor’s rationale? If, by the next day, the blood cultures proved that she did in fact have a blood-borne infection, he was confident the staff in the laboratory would communicate that finding to the staff in the emergency room, who, in turn, would contact the patient and make sure she returned for prompt, lifesaving treatment.

Unfortunately, no system to establish this line of critical communication had been set up at the hospital. The day after the patient was sent home from the emergency room, blood cultures were returned positive. This fact was communicated from the laboratory to the emergency room, but no one in the emergency room took the steps necessary to get the patient back for adequate treatment. Failure to immediately treat this blood-borne infection was tantamount to imposing a death sentence on the patient. The following day, one of the patient’s children found her unconscious on the bathroom floor. She was rushed to the hospital, but it was too late. The infection had traveled to her heart, causing a condition known as endocarditis. The patient died shortly after arriving at the emergency room.

After years of litigation, Atlee Hall lawyers were able to conclude the case for a substantial settlement. Perhaps more importantly, the lawsuit prompted the hospital to establish policies and procedures and staff training that will prevent a similar incident from ever occurring again. This result underscores the fact that lawsuits that hold doctors and hospitals responsible for their negligence makes our community a safer place for all.

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