Case Archive
Hospital Administration, Emergency Medicine
Ref. # 98887

On Christmas Eve a 72 year old Texas woman was taken to the ER due to shortness of breath. A chest X-ray and urinalysis were performed. The patient was diagnosed with pneumonia and discharged 3 1/2 hours later with instructions to drink plenty of fluids. After the patient left a radiologist read the X-rays as showing congestive heart failure; pneumonia was not included in the impression. This interpretation was not communicated to the patient. On New Year's Day the patient was taken by ambulance to the ER due to back, chest pain and coughing. Oxygen saturation was 86%. There was no reference to the chest X-rays taken the week prior. The patient was discharged three hours later with the diagnosis of cough. Two days later the woman had her family drive her to another hospital--several hundred miles away. She was diagnosed with congestive heart failure, cardiomyopathy, acute myocardial infarction and mitral regurgitation. She died three days later. A medQuest ER physician who is also a hospital administrator opined the ER department of the initial hospital and the treating physician deviated from the standard of care. The patient was not weighed, no EKG nor Arterial Blood Gases were obtained and the woman was not offered admission. The failure to notify the family of the results of the chest X-rays and to correct the mistreatment and misinformation constituted negligence. During the second ER visit the oxygen saturation was at a dangerously low level that required further testing. X-rays were not taken, there was no request for a pulmonary consult, and again hospital admission was not offered. The hospital did not meet the duty it owes to its patients.

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