In the midst of the internationally known Ebola scare, a Texas hospital sent a Liberian patient home with infection like symptoms, with no testing, after learning he had just come from disease ravaged West Africa. In doing so, the hospital's medical mistake needlessly endangered the lives of at least 46 people living in the Dallas community. Had the hospital followed basic protocol, if not simple common sense, the patient would have never been discharged.
First discovered in 1976, Ebola is a rare and deadly disease caused by infection with one of the Ebola virus strains. Ebola viruses are found in several African countries, including Liberia, which can strike humans and nonhuman primates. After over 3,000 reported deaths in Africa, the first known case Ebola arrived in the US last month.
On September 25, 2014, Texas Health Presbyterian Hospital in Dallas received a Liberian patient named Thomas Duncan. While taking Mr. Duncan's history, the 42-year-old male reported complaints of fever, abdominal pain, and headaches after recently arriving from Ebola stricken West Africa. Rather than run federally mandated tests for Ebola on patients with such symptoms, the hospital discharged Mr. Duncan back to the community assuming he had a low level infection. After Mr. Duncan returned to the hospital two days later with worsened symptoms, test results revealed Mr. Duncan has Ebola.
Initially, the hospital released a statement on September 28, 2014, blaming the premature discharge on a computer glitch. A week later, the hospital released a written statement on October 3, 2014 admitting the medical mistake was caused by human error. Indeed, Mr. Duncan's travel history was visible to every hospital staff member had any of them chosen to review the electronic record. Instead, the discharging physician sent Mr. Duncan home without reviewing the full medical record. Nor was there any apparent communication between that physician and the nurse who took Mr. Duncan's history about the patient's recent travel from West Africa.
As the recent Ebola misdiagnosis illustrates, hospital mistakes caused by miscommunication are an all too common source of medical malpractice. Fifteen years ago, the Institute of Medicine reported that between 44,000 and 98,000 people die every year in the US from preventable medical mistakes. An updated study reported in the Journal of Patient Safety last year now estimates the real number to be as high as 400,000. According to Dr. Marty Makary, a surgeon from John Hopkins University, breakdowns in communication between medical staff "are an epidemic in American health."
Death from Ebola is by no means a guarantee in the US with proper treatment. According to CDC Director Dr. Tom Frieden, "it's definitely possible to take care of patients with Ebola safely..." Sadly, the risk of death from preventable medical mistakes is far greater.
CDC, About Ebola Virus Disease, Last Reviewed October 3, 2014.
Reuters, Dallas Hospital Retracts Explanation For Missed Ebola Diagnosis, October 4, 2014.
Business Week, Hospital Mistakes Are Scarrier Than Risk Of Infection In US, September 20, 2014.