If you pay attention at all to news about medicine, you must have heard about the tragic death of a 12-year old boy who was seen and discharged from the emergency department of the prestigious New York University Medical Center. He had developed sepsis from what appears to have been a small cut and the diagnosis was missed. When he eventually returned to the ED and was admitted, it was too late and he died.

Many have commented on this sad story. The good people at ProPublica, some of whom I follow on Twitter, wrote about this and other types of medical errors in a piece entitled “Why Can’t Medicine Seem to Fix Simple Mistakes?” I will grant that some of the errors they mentioned, such as wrong-site surgery and reusing syringes, are indeed simple mistakes and should be 100% preventable.

But the death of young Rory Staunton, admittedly caused by medical errors, was not the result of “a simple mistake.” The ProPublica story says, “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.” Specifically, he had a number (said to have been five times the normal value) of immature white blood cells called “bands,” which is a sign of the body reacting to an infection.

While human errors were made, this event also fits James Reason’s “Swiss cheese model” of a complex series of occurrences that will take more than a new policy about notifying ED MDs about abnormal lab results to fix.

Since others who have written about this case also did not have all of the facts about it at their disposal, I won’t let that stop me either. Based on what I have read, I will point out the many areas where things may have gone wrong and why the outcome was not the result of a simple mistake. Disclaimer: I am not in any way trying to defend the actions of any of the doctors or hospital staff.

There is great pressure brought to bear on ED MDs to increase “throughput.” EDs are very crowded these days and beds do not even have chance to cool down between patients. I imagine the “move ‘em out” mentality played a role in what at first appeared to be a simple flu-like illness in a young boy.

Some have attempted to defend the ED MD by pointed out that a child’s heart rate is much more rapid at baseline that that of an adult or that fever increases heart rate by 10 beats for every degree of elevation, which is not a consistent finding. The problem with that line of reasoning is that this 12-year old boy was 5 feet 9 inches tall and 169 pounds. A heart rate of 140 is not normal. The ED was seeing some cases of the flu. This was a child with a fever, an upset stomach and dehydration. But in addition to his abnormal vital signs, he also could not walk and had leg pain, symptoms which are not usually associated with the flu. It seems that the history of mottled skin was not picked up by the ED MD.

The private pediatrician laments the fact that she was not given the results of the boy’s lab tests. The original article quotes her, “I never knew that testing was done.” She also said “I sent him to a major medical center.” She is on the staff of the hospital. Did she call the ED and tell anyone she was sending in a sick child with “mottled skin”? Does she have any responsibility to follow up on the referral of a patient of hers to the ED? Could she have accessed his ED chart and/or lab work via the electronic medical record?

Apparently the lab results were not printed until 3 hours after the child was discharged from the ED. 3 hours? It takes an automated CBC machine 5 minutes to run the test. The differential would have taken maybe 20 minutes. The result should have been available within 30 minutes. And printed? Who is still printing lab results? Pieces of paper get lost. Is it possible that NYU is still using a paper chart?

My rule has always been “If you order a test, it’s your responsibility to find out the result.” I guess that is not the way it went at NYU that day. I wonder if a shift change and sign out was involved. Of course, the patient would have been home already, but most EDs have the capacity to call a patient back if an overlooked or unexpected finding occurs.

After the discharge from the ED order was written, vital signs that were still ominous were again taken. No nurse or patient care technician thought to report those findings to the ED MD.

I feel very sorry for the family of the patient but I don’t blame them. They had faith in the doctors but it was misplaced. One must aggressively advocate for one’s loved ones. If the advice doesn’t seem right, ask questions. Get a second opinion.

A physician from another hospital suggested what may happened. He said, “The big questions are about how to integrate new information that doesn’t fit with the perception you have formed. How to listen to the patient when they are telling you something that doesn’t fit with your internal narrative of the case. These are the hardest things to do in medicine and yet the most important.”

From a follow-up article in the New York Times:

In a statement, the hospital said that emergency physicians and nurses would be “immediately notified of certain lab results suggestive of serious infection, such as elevated band counts.” The hospital has developed a new checklist to ensure that a doctor and nurse have conducted “a final review of all critical lab results and patient vital signs” before a patient leaves.

My concerns about the supposed remedy for this are what level of elevated bands, a very common finding in any type of infection, is going to prompt a call? The normal value for bands in a differential blood count is 3-5%. What will be the threshold? Will the ED be overloaded with false alarms?

NYU’s ED sees over 48,000 patient visits per year and its major affiliate and next door neighbor Bellevue Hospitals sees 89,000. Does anyone really think that a checklist is going to be filled out for every single ED visit at these two facilities?

Bottom line: The death of Rory Staunton was not the result of a simple mistake. A new policy and a checklist cannot guarantee that a similar tragedy will not occur. Although some system issues appear to have been in play here, human errors were made and cannot be totally obviated by any policy.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.