Hospital changes procedures after child’s death
NYU Langone Medical Center, part of New York University, has changed its procedures for handling potential cases of septic shock after the death of a 12-year-old boy who was misdiagnosed.
Rory Staunton was sent home from the hospital’s emergency department with a diagnosis of viral gastroenteritis, but three hours later a laboratory test at the hospital showed that his blood had extraordinarily high levels of cells associated with bacterial infections, according to information confirmed by the hospital. He subsequently went into shock and experienced organ failure. He died three days later, on April 1.
His parents issued a statement saying they were not told about the lab results and were unaware of how seriously ill their son was, having been assured that he was suffering from a typical stomach bug. In fact he was suffering septic shock brought on by an accident few days earlier when he cut his arm while diving for a basketball at his school gym.
Lisa Greiner, a spokeswoman for the hospital says that emergency physicians and nurses would be “immediately notified of certain lab results suggestive of serious infection, such as elevated band counts.” The child’s bands, a type of white blood cell, were nearly five times as high as a normal level. (See the story below for information on how hospitals are addressing septic shock.)
The hospital has developed a new checklist to ensure that a doctor and nurse have conducted a final review of all critical lab results and patient vital signs before a patient leaves, according to a hospital statement.
“Following our review of the events that led to this tragic loss, we have implemented corrective actions and are in the process of designing additional care processes to address the delivery of care to our ED patients,” the statement says. “We developed a new ED Discharge Checklist to make certain that the treating physician and nurse conduct a final review of all critical lab results and patient vital signs prior to the patient being discharged. Additionally, we are designing a process by which the attending ED physician is immediately notified of certain lab test results suggestive of serious infection, such as elevated band counts.
“In the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the ED, the patient will be called and the information will be shared with referring physician. Keeping our patients safe is our first priority, and we want to prevent this situation from happening again.”
NYU Langone Medical Center, part of New York University, has changed its procedures for handling potential cases of septic shock after the death of a 12-year-old boy who was misdiagnosed.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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