US Ebola patient zero, Thomas Eric Duncan, recent arrival from Liberia, had to go to Texas Health Presbyterian Hospital twice to get admitted. On his first go-round, the hospital sent him home with antibiotics even though a nurse had obtained information that he’d been in Liberia, and despite the fact that his symptoms were consistent with the early signs of Ebola.
If Duncan had been admitted on that initial visit his diagnosis would still have been a big story and a distressing one, but nothing as awful as the situation we’re currently in. That being said, it’s been difficult to obtain much information about how the mistake happened.
Here’s the relevant section of the initial press conference with hospital official, Dr. Mark Lester:
(INAUDIBLE QUESTION)LESTER: A checklist was in place for Ebola in this hospital for several weeks. And Dr. Ed Goodman (ph), to my right, had led the implementation of that. That checklist was utilized by the nurse who did ask that question. That nurse was part of a care team. And it was a complex care team taking care of him in the emergency department.Regretfully, that information was not fully communicated throughout the full team. And as a result, the full import of that information wasn’t factored into the clinical decision-making. The overall clinical presentation was not yet typical for Ebola; so as the team assessed him, they felt clinically it was a low-grade common viral disease. That was the presentation.(INAUDIBLE QUESTION)LESTER: He volunteered that he had traveled from Africa in response to the nurse operating the checklist and asking that question.(INAUDIBLE QUESTION)LESTER: I can’t answer that question because that’s one piece of information that would be factored into the entire clinical picture. The clinicians did not factor it in. So it was not part of their decision-making.(INAUDIBLE QUESTION)LESTER: I — that’s a question that’s really not in my domain.(INAUDIBLE QUESTION)LESTER: We are carefully assessing that now. And that is being investigated. So we are investigating it. I can’t give you specific information. We will look very carefully at that.QUESTION: Sir, would I – would I call that a misstep, would you not?LESTER: I would call that not factoring all the information among the team that was present so that all the information wasn’t present as they made their clinical decision.QUESTION: Was there any (ph) expressed any information that this person (INAUDIBLE).LESTER: That information was not obtained when the patient was in the emergency room.QUESTION: But do you know that now?QUESTION: (INAUDIBLE QUESTION) you name is, sir?LESTER: Oh, I’m Dr. Mark Lester…
We now have a more recent hospital statement that claims it was a software failure in the hospital’s electronic records system that was the culprit:
While the patient, Thomas Eric Duncan, told a nurse that he had been in Africa, that information wasn’t automatically included in electronic records seen by the doctor, according to a statement by Texas Health Presbyterian Hospital, where Duncan is being treated. The software is made by Epic Systems Corp., according to news releases and the hospital website.“As designed, the travel history would not automatically appear in the physician’s standard work flow” within the electronic records system, the hospital said.
But travel history is such a basic part of an infectious disease workup that this is an extraordinary glitch, if true. And if no one was aware of a flaw so basic, our reliance on electronic records could end up being a big mistake, with software taking over from human judgment and sometimes missing the obvious.
And then we have some new information which, if true, would not seem to reflect well on the hospital. The story comes from Duncan’s nephew Joe Weeks (who also is saying that Duncan is now too weak to talk to the family on the phone) [emphasis mine]:
Weeks also had concerns that the hospital wasn’t aware that Duncan may have been infected with Ebola. Weeks said that he called the hospital to report his concerns about Duncan’s condition – and when he didn’t get the reaction he wanted, he called officials at the Centers for Disease Control and Prevention and the Department of Health, at which point Duncan was put in isolation.“They had him in the ER, like any other patient, and I didn’t think that was the right procedure,” Weeks said.“I don’t know how long it was going to take, but I wasn’t trying to wait to see how long it was going to take, so I pre-empted and called CDC and reported that there might be a possible Ebola case in Texas. But the hospital was not doing what it needed to do at that time,” he said.
If Weeks’ narrative is true, we can consider it fortunate that he had the presence of mind to inform the CDC. If not for his doing so, there might have been an even longer delay in Duncan’s diagnosis, and his contacts might not have been traced and isolated until more time had passed.
Of course, Weeks may be making self-serving statements that are untrue; we have no way of knowing at this point. It would be good if the CDC could weigh in on it and either deny or confirm his story.
[Neo-neocon is a writer with degrees in law and family therapy, who blogs at neo-neocon.]
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