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.
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