Reporter notebook: Why I'm not surprised hospital missed Ebola

Hospital 'deeply sorry' for Ebola mistakes
Hospital 'deeply sorry' for Ebola mistakes

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Story highlights

  • Communication errors in hospitals can be deadly
  • The mistake in Dallas got a lot of attention because Ebola was involved
  • Similar, less high-profile mistakes, happen again and again, Cohen says
At a press conference in Dallas earlier this month, I listened as a hospital administrator made the now infamous revelation that a feverish man was allowed to go home from the emergency room even though he'd recently been in Liberia.
That man, of course, turned out to be Thomas Eric Duncan, who died the next week of Ebola.
Reporters looked at each other and gasped in surprise. How could they have let Duncan go home?
Not me. I thought, "It's happened again."
And again, and again and again. The way Texas Health Presbyterian Hospital explains it, a communication error seems to be the cause of their mistake. Such errors are the second leading cause of hospital mistakes, according to the Joint Commission, which accredits hospitals.
These hospital communication and teamwork breakdowns kill as many as 120,000 people each year, according to an analysis of published studies done by safety experts at Johns Hopkins Medicine. That's more than die from prostate, breast or colon cancer.
"I really wasn't surprised by this. This kind of thing happens all the time," said Dr. Peter Pronovost, vice president for patient safety and quality at Johns Hopkins Medicine and author of the book "Safe Patients, Smart Hospitals."
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An administrator at Texas Health Presbyterian Hospital said the emergency room nurse asked Duncan about his travel history, and he said he'd recently been to Liberia.
"Regretfully that information was not fully communicated throughout the full team, and as a result the full import of that information wasn't factored in to the clinical decision making," Dr. Mark Lester said at a press conference on October 1.
A day after Lester's comments, the hospital put out a statement saying a "flaw" in its electronic health record filing system caused the miscommunication when Duncan's travel history was entered in a portion that would not automatically appear in the section doctors access when evaluating a patient. However, on October 3, the hospital issued a clarification saying no such flaw existed.
While the chief clinical officer for the hospital's parent company apologized before Congress on Thursday for mistakes made in the initial treatment of Duncan, it has yet to be fully explained how the communication error happened.
That's unfortunate, because knowing exactly what happened that day in Dallas could help other hospitals avoid the same error -- something Presbyterian Hospital has said it wants to do.
Texas Health Resources' Dr. Daniel Varga did say in his testimony before the U.S. House Energy and Commerce Committee that the hospital has changed its screening process in the emergency department "to capture the patient's travel history at the first point of contact" with staff.
Varga said that the hospital has altered its electronic filing system to "increase the visibility and documentation of information related to travel history and infectious exposures related to (Ebola)."
Toward the end of the Dallas press conference, Judge Clay Jenkins, the official in charge of the local Ebola response, appeared to grow frustrated by questions about why Duncan was sent home.
"We can examine our navels for a week about what happened on September 26 at a great hospital or we can move forward and protect our citizens," said Jenkins, a Dallas County judge and director of the county's Homeland Security and Emergency Management.
"What Mayor (Mike) Rawlings and I chose to do, what the President and the CDC choose to do and what the governor is choosing to do -- we're going to move forward and keep people safe," he added.
When an airplane crashes, the National Transportation Safety Board tries to figure out what went wrong so perhaps such an incident may not occur again. That's not navel gazing -- that's protecting people.
It's possible -- indeed it's imperative -- to look forward and backward at the same time. An independent investigation would help make sure that no more potential Ebola patients will be sent back home.