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Why can't Medicine seem to fix simple mistakes?


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[h=4]Why Can’t Medicine Seem To Fix Simple Mistakes?[/h]July 24, 2012 NYU's Langone Medical Center announced this week that it was adopting new procedures after the death of a 12-year old boy from septic shock. The hospital's emergency room sent Rory Staunton home in March and then failed to notify his doctor or family of lab results showing he was suffering from a raging infection.

In response to the case, which was closely covered by The New York Times, the hospital promised a bunch of basic fixes: ER doctors should be immediately notified of certain abnormal lab results and, if such results come in after a patient is sent home, the hospital should call the patient and his doctor.

As veteran health reporters, we wish we could tell you that this case will spur changes in emergency rooms across the nation, that never again will a hospital make such an avoidable mistake. But, sadly, decades of experience covering such incidents suggest the medical system may prove resistant to change. Forget about every hospital rewriting its procedures. History suggests it would be a victory if NYU Langone manages to follow its own new rules as we all hope they will.

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Key words: "Closed-loop communication". Our ER group already does this very thing- abnormal results are brought to our attention, and if they are sent home prior to us getting that info - which quite honestly SHOULDN'T happen because if you order a test in the ED, then you better wait for it before making a disposition - we call them and their doctor (if they have one). You close the loop.

 

That being said, without knowing any other particulars in the case, there will always be mistakes/communication issues/errors that will result in morbidity and mortality.

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Thanks for your input True Anomoly. I am glad that your ER is progressive enough to have already incorporated this protocol into your practice management. My concerns are for those who have not and more importantly, for our colleagues who don't read protocols and commit this error of ommission which can create the M&M that you speak of and then perhaps discover that this oversight eliminates them from their hospital umbrella policy.

I have practiced as a P for forty years and remain in practice today. I know that we can all fail to diagnose, particularly the younger PAs among us as years of practice equals a residency. Remember, it's not what I know but what I don't know because I have not seen it or studied it. This is the area where we are all subject to scrutiny.

Bob

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Must be just that hospital then. Dumb policies. Our hospital has been doing it for years. Notify any ER physician who is working, and they are required to call patients ASAP.

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