Errors and omissions

September 17, 2006 -- Today the ABC News site posted an item headlined "Illinois Woman's ER Wait Death Ruled Homicide; Long ER Waits Plague Nation's Hospitals." The item describes a woman who was, sadly, found dead in an emergency department waiting room in July two hours after a nurse told her to wait. The coroner found that the woman had presented with "classic symptoms of a heart attack." The coroner's jury ruled the death a homicide, which could lead to criminal prosecution. The piece rightly highlights the serious consequences that may occur if a triage nurse makes an error, and it also links the apparent problem here to ED overcrowding. But the piece appears to wrongly assume that physicians are ultimately responsible for all ED care. Thus, it consults no nurse experts. It relies instead on comments from the American College of Emergency Physicians (ACEP). These seem reasonable, but they blur the fact that ED triage is a nursing task. And a statement attributed to the president of ACEP advises dissatisfied patients to talk to the triage nurse, but if that "doesn't work," to "ask to speak to the emergency physician." This will reinforce the impression that ED nurses report to physicians, and that physicians are the real triage experts. In fact, patients in such a situation should generally ask to speak with the charge nurse, the clinical nurse specialist or the ED nurse manager.

The uncredited piece reports that Beatrice Vance, 49, went to the ED at Vista Medical Center in Lake County, IL, with nausea, shortness of breath, and chest pains. "A nurse saw her briefly and told her to wait." When the woman's name was called two hours later, she was dead. The coroner, Dr. Richard Keller, found that her "classic" heart attack symptoms meant she should have been seen more quickly. The coroner's jury ruled her death a homicide. Keller asserted that this case was a homicide because it presented a "willful or wanton act or recklessness." However, it's not clear from the facts in this piece how the alleged error here differs from negligent care-related acts that do not result in findings of homicide. The piece notes that the American Heart Association recommends immediate heart monitoring and an electrocardiogram within 10 minutes for those having a heart attack, which the coroner said did not happen in the Vance case. Of course, that assumes the attack has been diagnosed. The piece reports that the hospital "is not commenting" on the ruling. But it does not appear to have occurred to the reporter to identify or request comment from the triage nurse. This may seem to serve that nurse's immediate interests, or even those of nursing, by burying the nursing responsibility. But it also suggests that nurses are not real professionals, and that the responsibility for all care ultimately lies with physicians and "the hospital."

The piece goes on to provide helpful context about the stress under which EDs operate today. Long waits are common, and as a quote from ACEP's Leigh Vinocur suggests, this is due at least in part to the rising number of uninsured. Dr. Vinocur does note that (in the piece's words) "staff members" are trained to give immediate care to those who need that. He says that it's not "first come, first serve," and that "if you think you haven't been triaged correctly, tell them you want to be reassessed." The piece closes with the following statements:

According to the president of the American College of Emergency Physicians, if patients don't feel they're getting the care they need, they should try to talk with the triage nurse. If that doesn't work, patients should ask to speak to the emergency physician. Patients should not leave the emergency room if they feel their lives are in jeopardy.

These comments seem reasonable, but they also reinforce the mistaken idea that physicians are in charge of triage. Moreover, no nurse expert is consulted for the piece, even though the triage nurse's action appears to be the main issue here. In addition to the Illinois nurse in question, those responsible for this piece should have sought expert comment from the Emergency Nurses Association or some other reputable nursing source. Such a source could have spoken with authority on issues and challenges in the triage process. One specific issue a nurse might have raised is short-staffing, which is to some extent the flip side of the overcrowding point Vinocur raises, but one that readers might link more directly to funding decisions at the ED itself.

ACEP president Frederick Blum--whose name is inexplicably omitted here--at least advises patients to start with the triage nurse. But rather than suggesting that those who are still dissatisfied speak with someone higher up in the nursing staff, Dr. Blum suggests that patients then ask for a physician. That will reinforce the misimpression most readers already have that the nurse reports to a physician. Of course, based on this piece, Ms. Vance might have benefited from asking for either one. But the message conveyed in stories like this matters for nursing, because too many people believe that nursing is merely a lesser subsidiary of medicine, rather than an autonomous profession. It's hard to imagine a reader getting that the nurse involved here faces the possibility of independent malpractice liability for his or her actions.

We hope that the next time ABC News examines an alleged nursing error, it will seek expert comment from nurses.

See the ABC News report "Illinois Woman's ER Wait Death Ruled Homicide: Long ER Waits Plague Nation's Hospitals" from September 17, 2006.

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