Thursday, October 02, 2014

There's many a slip 'twixt the cup and the lip

"How could it happen?" is the question everyone's asking.

No, not the guy who walked into the White House past the Secret Service.

The nurse who asked the question.  CNN reports:

The first person to be diagnosed with Ebola on American soil went to the emergency room last week, but was released from the hospital even though he told staff he had traveled from Liberia.

Hospital officials have acknowledged that the patient's travel history wasn't "fully communicated" to doctors, but also said in a statement Wednesday that based on his symptoms, there was no reason to admit him when he first came to the emergency room last Thursday night.

A nurse asked the patient about his recent travels while he was in the emergency room, and the patient said he had been in Africa, said Dr. Mark Lester, executive vice president of Texas Health Resources. But that information was not "fully communicated" to the medical team, Lester said.

The man underwent basic blood tests, but not an Ebola screening, and was sent home with antibiotics, said Dr. Edward Goodman with Texas Health Presbyterian Hospital.

Three days later, the man returned to the facility, where it was determined that he probably had Ebola. He was then isolated.

There are probably several reasons. The simplest one, "the nurse messed," up might be correct, but it is also likely to be incomplete.  If a full-scale root cause analysis were conducted, we'd probably learn about any of the following: a lack of training of front-line clinical staff with regard to this disease, a series of protocols that are not attuned to this new and rare disease, and/or habitual poor communication between the triage staff and others.

Let's hope the country learns from this experience.  That's a most important task for the CDC to focus on right now.

Think how powerful a teaching tool this would be: If the nurse and MDs at Texas Health produced a 7-minute YouTube video of what went wrong and how they've changed their protocols.  That would go, er, viral within hours.


nonlocal MD said...

I don't think anyone who has ever worked in a hospital is surprised to hear this. However, I share your hope that it can be used to make both the public and those who don't feel the urgency to correct these problems, to wake up STAT.

Marilyn said...

As a nurse, this story makes my blood boil!It has the ring of "when all else fails, blame the nurse."

If she/he didn't "fully communicate" this critical information, one has to wonder why. Was her/his input routinely discouraged or dismissed? Did negative reinforcement and a lack of collegiality lead to silence?

Nevertheless, the doctors are not off the hook here. Why didn't they ask the critical questions themselves? They are responsible for their own practice as is the nurse.

Given all the information out there about Ebola, this is such a disappointing system failure.

So Sad.