Fatal Consequences of Inadequate Triage in the ED

Description

The failure to appropriately assess and triage a patient with syncope in the emergency department (ED) led to the patient’s death.

Clinical Sequence  

A 49-year-old patient with an unknown medical history was taken via ambulance to the ED at 4:00 pm after fainting in a grocery store. While in the ambulance, the patient refused to have their vital signs taken because they were cold and didn’t want to take their jacket off. The patient stated they felt tired and “unhealthy” but did not elaborate on the symptoms. In the ED, the patient was taken to the triage area. The Triage Nurse, who was a locum tenens temporary employee, placed the patient in a wheelchair without taking vital signs and brought the patient to the waiting room (the nurse later falsified the medical record to reflect that they did assess the patient upon arrival).

The receptionist in the waiting room noted that the patient had their head slumped down on their chest the entire time. No one checked the patient’s vital signs or condition for two hours. At 6:00 pm, the receptionist noted that the patient was unresponsive and called an RN to check on them. The patient was noted to have mottled skin and no respirations. Cardiopulmonary resuscitation was started; however, the efforts were unsuccessful, and the patient was pronounced dead.

An autopsy revealed severe atrophy of the adrenal cortex common with adrenal insufficiency (Addison’s disease). Experts believe the patient was likely suffering from an electrolyte imbalance due to the disease that interfered with their cardiac rhythm resulting in arrest. Experts opined that if the patient had been assessed earlier, their vital signs would have been abnormal prompting further investigation and treatment that would have stabilized them.

Allegation

A lack of timely assessment resulted in the patient’s death.

Disposition

The case was settled in the medium range.

Clinical Analysis 

• Adrenal insufficiency (Addison’s disease) can present with dehydration, weakness, dizziness, fatigue, and low sodium levels, among other symptoms. If left untreated, it can result in adrenal crisis and death.
• In this case, the EMT and the nurse failed to assess the patient’s vital signs after losing consciousness. The triage nurse’s role is to assess each patient upon arrival in the emergency room to determine how quickly they should be seen. The assessment should include vital signs and a medical history.
• Falsifying the medical record is a crime that can result in serious legal and patient safety consequences. Medical record alterations done incorrectly or in bad faith violate the Health Insurance Portability and Accountability Act (HIPAA) and can lead to harmful errors.

Discussion Questions 

• With emergency room overcrowding, what processes are in place to follow up on patients in the waiting room?
• What training do your triage nurses undergo?
• What efforts are in place to manage patient flow in the hospital in an effort to mitigate overcrowding in the ED?

References 

• Can Triage Nurses Accurately Predict Patient Dispositions in the Emergency Department?
• Emergency Nursing Triage: Keeping It Safe
• The Effect of Emergency Department Nurse Experience on Triage Decision Making
• The Association between Emergency Department Overcrowding and Delay in Treatment: A Systematic Review