The worst case scenario: When not using evidence produces fatal outcomes

So you've probably heard by now of the terrible event that occurred in a California ER this week where a woman bled to death while her family members stood by helplessly calling 911 for help. First, let's get this straight: if your patients are calling 911 from the ER, there's probably some evidence that a breakdown in communication is occurring somewhere in your organization. Beyond the phone calls, though, it seems like someone vomiting (and vomiting blood, no less) might signal a true emergency. So despite what seemed like overwhelming evidence that this woman was in need of help, nothing was done.

So what do we do about these Failure to Rescues? How do we prevent them? What evidence could have been used so that this didn't happen?

Recently I received in the mail from AHRQ information about Team STEPPS, a set of evidence-based tools to help train clinicians in teamwork and communication skills to reduce risks to patient safety. Many healthcare organizations are beginning to use it but I wonder if any in Oklahoma are using it. Personally, it looks like a great model that could really transform the way we communicate in healthcare.

I'm also curious to know if the fact that these were primary-Spanish speakers in any way influenced how they were treated. It certainly calls up the importance of medical interpretation and cultural competency in our healthcare organizations. Even that is really no excuse since a woman vomiting blood doesn't need much interpretation.

Let's make sure that what happened to Edith Isabel Rodriguez doesn't happen in Oklahoma and actually improves what we can do for patients in desperate need.

1. Have any of you heard about Team STEPPS or know someone using it?
2. Do you think a lack of cultural competency on the healthcare organization's part influenced the care they provided (or, actually, didn't provide)?