Report details errors in waiting-room death

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

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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