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Olive View ER patient wasn't assigned a doctor for 2 days, memo says

The hospital's patient safety officer cites a series of mistakes, described as a 'Swiss cheese' event, regarding the patient's care. He says it may not be a isolated incident.

November 05, 2010|By Molly Hennessy-Fiske, Los Angeles Times

In a series of mistakes described as a "Swiss cheese" event by hospital officials, a patient recently admitted to Olive View- UCLA Medical Center was not assigned a doctor for two days.

The patient was admitted to the Los Angeles County teaching hospital in Sylmar by an emergency room medical student, who filled out the admitting paperwork incorrectly despite help from an attending physician in the emergency room.

Although a doctor's name was placed on the paperwork, the doctor was never called about the assignment, according to a memo by Dr. Mark Richman, who said he was the attending physician who helped the student with the paperwork. The memo was sent to the hospital staff Oct 12.

Richman, the hospital's patient safety and clinical information technology officer, said the patient "sat for two days, getting medical care, but not under the care of a team, and without documentation in the form of an intern, resident or attending H&P (history and physical) or progress notes."

"The circumstances leading to this reflect what is known in the patient safety field as a 'Swiss cheese' event in which a series of events occurs, each of which bypasses an expected blockade of an error," Richman wrote.

Richman said the problem may not be an isolated incident, raising concern that medical students, interns and fellows in other departments at the hospital also might be unaware that admission often is a two-step process.

Richman's memo did not identify the medical student or the patient, when the patient was admitted to the hospital, what the patient was being treated for or how the mistake was discovered.

In order to prevent the incident from happening again, Richman wrote that "several gaps will be plugged," including ensuring that doctors page the doctor they assign a patient to and train medical students during orientation on how to admit patients.

Richman did not return an e-mail or phone calls Thursday. Hospital officials also did not return calls Thursday.

Carol Meyer, chief network officer for the Los Angeles County Department of Health Services, said department officials are investigating the incident.

Michael Wilson, a spokesman for the Department of Health Services, said the incident had not been reported to state regulators and that he could not comment further because of state and federal privacy laws.

The California Department of Public Health is investigating the incident, said spokesman Ralph Montano. He said Thursday he could not release details about its inquiry.

molly.hennessy-fiske@latimes.com

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