On April 1, 2012, twelve-year-old Rory Staunton died of septic shock bought on by a bacterial infection he received after diving for a basketball in his school’s gym. Prior to his death, Rory had experienced a high fever, vomiting, and pain in his leg. After visiting his family pediatrician, he was sent to NYU Langone Medical Center, a premier medical facility in New York, to be treated for what physicians thought was “a sick stomach and dehydration” (Dwyer, 2012). At NYU Langone, he was given medication and sent home. Two days later, Rory would be gone.
While in the hospital, Rory had undergone lab tests and his results came in after his discharge. The lab results showed signs of an infection, but the Staunton family was never notified of this. Rory’s family pediatrician also wrote in her notes that the patient had “mottling [skin which] could mean that vessels in his skin were constricting from low blood pressure” (Dwyer, 2012). The hospital records “do not reflect any communication with” the family pediatrician or her findings about Rory’s skin (Dwyer, 2012).
In response to the death, NYU Langone has recently implemented a new patient discharge procedure. In the new procedure, “emergency physicians and nurses would be ‘immediately notified of certain lab results suggestive of serious infection’” which Rory’s lab results showed (Dwyer, 2012). NYU Langone’s new checklist will also ensure that “a doctor and nurse have conducted “a final review of all critical lab results and patient vital signs” before a patient leaves” (Dwyer, 2012). The hospital further elaborated that “in the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the E.D., the patient will be called, and the information will be shared with referring physician” (Dwyer, 2012).
While it is good that the hospital is making strides to improve procedures after such poor quality, such things should be preventable. The main issue is the lack of communication between the pediatrician and the ER doctors. The pediatrician should have ensured that the family had the information to give to the ER doctors if there was not a way to send it electronically. Yet the biggest error in this case is no one informing the family about the abnormal lab test results. While it is unknown what procedure NYU Langone had prior to this, such a simple act of communication could have prevented an untimely death.
Providing quality care depends wholly on receiving quality information. Providers who do not have all pertinent information cannot effectively treat patients. Simple acts such as appropriate communication and dialogue can save lives. This summer, I had two courses in which group work was required. In both groups, communication was critical to get information and provide quality work. If such a basic skill is stressed in school, why is it not practiced in hospitals? Why were Rory’s medical records not sent to NYU Langone? And most importantly, why was the family not notified of abnormal lab test results?
While it is easy to point fingers, we must not forget that ineffective processes can cause as much harm as human error. This case should have administrators thinking about the quality of the processes that are in place for labs to communicate to physicians thorough the hospital. A quality program where systems are integrated and communicating to one another can increase patient safety and quality of care provided. While it is unfortunate that a young child had to lose his life, this story can certainly be a teaching moment for all healthcare providers. And while it is important that processes are improved, they must be continuously updated to reflect changes and prevent possible issues.
Dwyer, J. (2012, July 11). The New York Times. Retrieved July 20, 2012, from www.nytimes.com: http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?pagewanted=all
