Unfair, unjust, and ineffective

An article from the Western Journal of Emergency Medicine (Western J Emerg Med. 2014;15(2):137-141) offers a frightening example of blatantly systemic problems in a hospital that lead to a patient's death, which is then blamed on an emergency physician, who then faces a loss of licensure.  It is a truly awful case, on so many levels.

As Howard Ovens, Director of the Schwartz/Reisman Emergency Centre at Toronto's Mt. Sinai Hospital, notes: 

Besides the slack and cowardly administration, the expert opinions were flawed, and the process was unfair and probably would not have withstood a court challenge (EP was repeatedly not represented when judgments were made about him).  Finally, every principle of the patient safety movement with regard to not blaming individuals for system problems has been violated.

The abstract:

 

We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity. His initial symptoms of shortness of breath and feeling ill for several days were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory studies, which suggested mild diabetic ketoacidosis. His medical care in the ED was conducted in a crowded hallway. After correction of his metabolic abnormalities he felt improved and was discharged with arrangements made for outpatient follow-up. Two days later he returned in cardiac arrest, and resuscitation efforts failed. The autopsy was significant for multiple acute and chronic pulmonary emboli but no coronary artery disease. The hospital settled the case for $1 million and allocated major responsibility to the treating emergency physician (EP). As a result the state medical board named the EP in a disciplinary action, claiming negligence because the EKG had not been personally interpreted by that physician. A formal hearing was conducted with the EP's medical license placed in jeopardy. This case illustrates the risk to EPs who treat patients in crowded hallways, where it is difficult to provide the highest level of care. This case also demonstrates the failure of hospital administration to accept responsibility and provide resources to the ED to ensure patient safety.