Report details errors in waiting-room death

Jan. 26th, 2010 by Andrew Van Dam
Filed under: Hospitals, Hot Health Headline, Nursing 

The Philadelphia Inquirer’s Tom Avril reports on how hospital errors led to the death of a 63-year-old north Philadelphia guidance counselor. Avril opens his story by painting a picture of hospital operations, one based on documents released after a state investigation.

electronic medical recordsPhoto by exvertebrate via Flickr

Twice, when an emergency-room nurse called out the name of Joaquin Rivera and he did not respond, she had no idea he’d already suffered a massive heart attack.

The reason: The nurse did not venture beyond the waiting-room doorway and simply did not see him where he sat, unattended, for nearly an hour.

Avril reported that the hospital has already taken steps to prevent a similar occurrence in the future, including:

  • Increasing security by more than 30 percent
  • Creating new training for registration staff, with an emphasis on communication with nurses
  • Instituting a policy of calling patient names every 10 minutes if they don’t answer at first
  • Identifying a location on the waiting-room floor from which all parts of the room can be seen and marking it with tape so that triage nurses know where to stand when calling out names
  • Hiring an architectural firm to see if further improvements can be made


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  1. uberVU - social comments on Wed, 27th Jan 2010 8:46 pm
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