Tag Archives: Wait times

Man Found Dead After Waiting 8 Hours for Emergency Treatment

By ThinkReliability Staff

A man seeking treatment for a rash at a Bronx hospital emergency room (ER) was found dead eight hours later, still in the waiting room, of as-yet unknown cause.  The incident is currently under investigation by the New York State Department of Health and the cause of death will be determined by a medical examiner.

When performing an investigation of a case like this one, it’s important to focus on the goals that were impacted by the incident and determine all the causes that resulted in the goals being impacted, not just finding one “root” cause.  In this case, the impact to the patient safety goal has clearly been impacted because of the death of a patient within the hospital itself waiting to be seen.  The patient service goal was clearly impacted because the patient did not see a doctor in the six hours – or more – between arrival and his death.  The schedule goal is impacted by the significantly higher-than-average wait at this particular ER.  Lastly, the labor goal appears to be impacted by insufficient staffing levels.

According to the hospital, the cause of the patient’s death is simple.  Per the Hospital spokesperson: “His name was called several times on several occasions, and he did not respond… People have personal responsibility when your name is called, you have to get up and see the doctor.”  The hospital says that all guidelines were met and, even goes so far to add that “probably this scenario in this shape and form has happened in any big hospital in New York City.”

Many don’t find that answer acceptable. Although hospital guidelines may have been followed, there’s no discussion of whether the guidelines were adequate.  It is apparent that the hospital guidelines do not include any sort of care or supervisor for patients prior to being called in to the waiting room.  However, there’s no discussion of whether that meets the standard of care expected of these hospitals.  As this lack of oversight resulted in the death of a patient going unnoticed – potentially for hours – in a hospital waiting room.

In addition, the incident has brought up questions about the impact of the long wait time.  The wait at the emergency room for this hospital is an average of 306 minutes – more than 5 hours.  The national average is 137 minutes and the average in the state of New York is 155 minutes.  When the patient was called, starting at 2 and a half hours after entry, he may have well been asleep, given that the next interaction he had was with a security guard who woke everyone in the waiting room at 2 a.m.  This periodic waking of people in the waiting room – meant to ensure that nobody was using the waiting room as a shelter – next happened at 6:40 AM, and is when the patient was found dead.  Unofficial reports suggest the patient may have been dead for hours.  The patient was last seen moving at 3:45 AM on security cameras.

These questions demonstrate the fallacy of the one “root” cause approach.  The hospital’s assessment begins – and ends – with placing blame on the patient for not responding to a call in the ER.  But this expectation may not be appropriate in all cases.  Although a shorter ER wait time may or may not have saved the life of the patient in this case, it would certainly ease the strain of an ER visit for most patients and potentially save a life.  There have been several publicized cases of deaths or significant disabilities resulting from waiting too long in the ER.  Certainly an incident like this occurring at a hospital merits a review of policies that allowed a man to die unnoticed by staff.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here and here to read more.

ER Wait Leads to Amputation

By ThinkReliability Staff

In some cases, it’s easy to equate “cause” with “blame”.  Sadly that seems to be the case for the family of a 2-year old triple amputee from Sacramento, where a near-certain malpractice suit looms.  The fundamental question in this story is whether or not Malyia Jeffers would have come so close to death had she been diagnosed and treated sooner, upon arriving at the emergency room.

Malyia, bruised, feverish and weak, waited with her family in her local hospital’s emergency room for five hours.  Originally assessed as sick with only a virus and a rash, her parents suspected something more.  Once again a triage nurse reassessed Malyia as non-urgent, with just a virus and rash.  Finally as her small body went limp, her frantic father barged past the ER nurses’ station to demand a second opinion.  That move is probably what saved her life, as blood tests soon confirmed liver failure due to group A streptococcus (GAS).  Two hospital transfers later, Malyia was on life support and blood pressure medication which kept her heart beating and ultimately saved her life.  The lack of oxygen to her limbs however forced doctors to amputate her left hand, fingers on her right hand and both of her lower legs three weeks after her initial infection.

According to the Center for Disease Control, “severe, sometimes life-threatening, GAS disease may occur when bacteria get into parts of the body where bacteria usually are not found, such as the blood, muscle, or the lungs…Streptococcal toxic shock syndrome (STSS) results in a rapid drop in blood pressure and organs (e.g., kidney, liver, lungs) to fail. While 10%-15% of patients with invasive group A streptococcal disease die from their infection, more than 35% with STSS die.”  Doctors know that early diagnosis and treatment are critical with aggressive bacteria such as GAS.  Would Malyia have fared better had she been seen sooner?

Emergency room waiting times have exploded in recent years.  If you were to ask someone on the street why, you might guess that the biggest contributing factor is the growing number of uninsured patients.  Not so, according to an extensive 2009 government report.  Long wait times are actually a symptom of a complex problem.  Vacant hospital beds, specialist availability and access to primary care all play a part in why emergency rooms, especially metropolitan ones, are constantly full.  Using a Cause Map, it is easier to see exactly why.

While Cause Mapping might help us see why ER wait times are a complex issue, it doesn’t alleviate the suffering the Jeffers family has and will face in the months and years to come.   Unfortunately it is tempting to point fingers and place blame.  Yet the reasons behind this tragic cause are not so simple.  Hopefully, process improvements will alleviate the suffering of those stuck waiting in the ER.

More information on the story can be found in the Sacramento Bee.  A 2009 GAO report also provided helpful information on the nation-wide issue of emergency room waiting times.