A man seeking treatment for a rash at a Bronx hospital emergency room (ER) was found dead eight hours later, still in the waiting room, of as-yet unknown cause. The incident is currently under investigation by the New York State Department of Health and the cause of death will be determined by a medical examiner.
When performing an investigation of a case like this one, it’s important to focus on the goals that were impacted by the incident and determine all the causes that resulted in the goals being impacted, not just finding one “root” cause. In this case, the impact to the patient safety goal has clearly been impacted because of the death of a patient within the hospital itself waiting to be seen. The patient service goal was clearly impacted because the patient did not see a doctor in the six hours – or more – between arrival and his death. The schedule goal is impacted by the significantly higher-than-average wait at this particular ER. Lastly, the labor goal appears to be impacted by insufficient staffing levels.
According to the hospital, the cause of the patient’s death is simple. Per the Hospital spokesperson: “His name was called several times on several occasions, and he did not respond… People have personal responsibility when your name is called, you have to get up and see the doctor.” The hospital says that all guidelines were met and, even goes so far to add that “probably this scenario in this shape and form has happened in any big hospital in New York City.”
Many don’t find that answer acceptable. Although hospital guidelines may have been followed, there’s no discussion of whether the guidelines were adequate. It is apparent that the hospital guidelines do not include any sort of care or supervisor for patients prior to being called in to the waiting room. However, there’s no discussion of whether that meets the standard of care expected of these hospitals. As this lack of oversight resulted in the death of a patient going unnoticed – potentially for hours – in a hospital waiting room.
In addition, the incident has brought up questions about the impact of the long wait time. The wait at the emergency room for this hospital is an average of 306 minutes – more than 5 hours. The national average is 137 minutes and the average in the state of New York is 155 minutes. When the patient was called, starting at 2 and a half hours after entry, he may have well been asleep, given that the next interaction he had was with a security guard who woke everyone in the waiting room at 2 a.m. This periodic waking of people in the waiting room – meant to ensure that nobody was using the waiting room as a shelter – next happened at 6:40 AM, and is when the patient was found dead. Unofficial reports suggest the patient may have been dead for hours. The patient was last seen moving at 3:45 AM on security cameras.
These questions demonstrate the fallacy of the one “root” cause approach. The hospital’s assessment begins – and ends – with placing blame on the patient for not responding to a call in the ER. But this expectation may not be appropriate in all cases. Although a shorter ER wait time may or may not have saved the life of the patient in this case, it would certainly ease the strain of an ER visit for most patients and potentially save a life. There have been several publicized cases of deaths or significant disabilities resulting from waiting too long in the ER. Certainly an incident like this occurring at a hospital merits a review of policies that allowed a man to die unnoticed by staff.
To view the Outline and Cause Map, please click “Download PDF” above. Or click here and here to read more.