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Ebola death illustrates consequences of communication errors in health care settings

| Oct 23, 2014 | Medical Malpractice

When dealing with an individual’s health and a possible medical emergency, finding a way to capture and communicate vital medical information is paramount. A recent example of the devastating consequences that may result when health care professionals fail to effectively communicate involves the case of the first U.S. Ebola victim, Thomas Duncan.

An NBC News timeline details when Duncan was likely exposed to Ebola and the events that transpired thereafter. While in Liberia, Duncan helped a pregnant neighbor infected with Ebola get to the hospital on Sept. 15. On Sept. 20 he arrived in the U.S. to visit family and friends. Feeling ill, on Sept. 26, Duncan sought medical care at a Dallas hospital. At that time, however, the possible source of Duncan’s illness was not diagnosed as Ebola and he was sent home only to arrive by ambulance two days later and be quarantined with the deadly disease.

Duncan subsequently died and the health, safety and very lives of several individuals who may have come into contact with Duncan after his initial misdiagnosis were put at risk. How did this medical mistake happen? Why didn’t the doctor who initially examined Duncan know the man had recently traveled to the U.S. from Liberia?

The Dallas hospital has since come forward to report that the intake nurse correctly entered information related to Duncan’s recent travel activity in the patient’s electronic health record. That information, however, was not visible to the doctor who subsequently examined Duncan as the system apparently didn’t deem travel information to be important to a patient’s diagnosis.

While the reporting error with this specific EHR system has since been fixed, this very public and tragic case raises additional questions and concerns about how pertinent medical information is and is not being communicated to and seen by U.S. doctors who are responsible for providing everyday medical care to millions of men, women and children.

Communication failures or shortcomings occur with far too much frequency in hospital settings and, as this case illustrates, are not solved by the use of EHRs. One doctor and patient safety advocate cites patient handoffs as being a time when breakdowns in communication are particularly common and harmful to patients whose very lives may depend on whether important information is correctly documented, communicated and interpreted.

Source: Bloomberg Businessweek, “Scarier Than Ebola: Human Error,” John Tozzi, Oct. 3, 2014

NBC News, “Timeline: How Ebola Made Its Way to the U.S.,” Tom Winter, M.L. Flynn and Robert Dembo, Oct. 2, 2014

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